Afferent loop obstruction with obstructive jaundice and ileus due to an enterolith after distal gastrectomy: A case report

Afferent loop obstruction induced by undigested food (phytobezoar) treated through endoscopic fragmentation with biopsy forceps: A case report

INTRODUCTION AND IMPORTANCE

Afferent loop obstruction (ALO) can occur as a complication of gastrectomy with Billroth II or Roux-en-Y reconstruction. Conventionally, emergent surgery was performed for most cases, while endoscopic procedures for elective cases have been reported more recently. We report a unique case of ALO caused by a phytobezoar that was successfully treated by endoscopic procedures.

CASE PRESENTATION

A 76-year-old female patient presented with epigastric pain for several hours after dinner. The patient had a history of distal gastrectomy with Roux-Y reconstruction for gastric cancer at age 62. Computed tomography (CT) demonstrated evident dilation of the duodenum and common bile duct, and detected a bezoar at the jejunojujunal anastomosis site, indicating that the ALO was induced by the bezoar. Upper endoscopy visualized undigested food formation stuck at the anastomosis site, and it was successfully dislodged by endoscopic fragmentation using biopsy forceps. After the procedure, the abdominal symptoms subsided, and the patient was discharged on the fourth day.

CLINICAL DISCUSSION

Bezoar-induced ALO is rare. In this case, CT helped diagnose the ALO induced by the bezoar. In recent times, there has been a rise in endoscopic interventions for ALO, and there are some reports of bezoar-induced small bowel obstruction being treated endoscopically. Therefore, a subsequent endoscopic examination was performed, confirming the presence of a phytobezoar and leading to a less invasive endoscopic fragmentation treatment in this case.

CONCLUSION

This is a unique case report of phytobezoar-induced ALO treated by endoscopic fragmentation of undigested food, providing a beneficial treatment option.

Bezoar as a cause of jejunal afferent loop mass after pylorus preserving pancreaticoduodedectomy: A case report

INTRODUCTION AND IMPORTANCE

Bezoars may occur in patients after undergoing gastric surgery. Most bezoars are discovered due to small intestine obstruction, causing acute abdomen.

CASE PRESENTATION

A 44-year-old woman with a history of intraductal papillary mucinous tumor of the pancreas was initially treated with pylorus-preserving pancreaticoduodenectomy. Two years ago, she had intermittent abdominal pain with no noted abnormality on computed tomography (CT) scan and gastroscopy. During her follow-up, an abdominal CT scan revealed a 1.8-cm low-enhancing nodular tumor with minute central calcification at the afferent loop of the jejunum, later diagnosed as a jejunal tumor. Endoscopy helped determine the location and characteristics of the tumor. Endoscopic findings revealed a bezoar approximately 3 cm below the pancreaticojejunostomy and hepaticojejunostomy, at the end of the afferent loop of the jejunum. Removal using an endoscopic basket failed as the bezoar broke halfway. Residual suture material was found inside the bezoar. Since the size of the bezoar decreased, the procedure was discontinued to allow it to dislodge naturally.

CLINICAL DISCUSSION

Bezoars may be caused by gastric surgery, increased fiber diet, and psychiatric illness. As seen in this case, residual suture material caused bezoar formation. Bezoars mainly occur in the stomach and small intestines, but they can also occur in the afferent jejunal loop, as seen in this case.

CONCLUSION

Surgeons should be careful not to leave behind suture material during gastric surgery. However, bezoar formation should be considered in patients complaining of abdominal pain even if they did not undergo gastrectomy.

Nontraumatic perforation of the small intestine caused by true primary enteroliths associated with radiation enteritis: a case report

Background

True primary enterolithiasis is an uncommon condition, and nontraumatic perforation of the small intestine (NTPSI) is also an unusual entity. Therefore, NTPSI due to true primary enteroliths is an exceptionally rare complication. Moreover, enterolithiasis and radiation enteritis are also unique combinations. Herein, we present an exceedingly rare case of NTPSI induced by multiple true primary enteroliths associated with radiation enteritis.

Case presentation

A 92-year-old woman with acute abdominal pain was transferred to our hospital because a computed tomography (CT) scan performed by her family doctor revealed free air and fluid collection within her abdomen. Our initial diagnosis was upper gastrointestinal perforation, and we selected nonoperative management (NOM) with adnominal drainage. Although her general condition was stable, jejunal juice was drained continuously. Given that the CT performed 10 days after onset demonstrated perforation of the small intestine and adjacent concretion, we performed an emergency partial resection of the small intestine and jejunostomy. The resected bowel was 1 m in length and had many strictures that contained multiple enteroliths in their proximal lumens. The patient’s postoperative course was uneventful. The enteroliths were composed of deoxycholic acid (DCA). She was diagnosed with peritonitis due to NTPSI derived from multiple true primary enteroliths associated with radiation enteritis, as she had previously undergone hysterectomy and subsequent internal radiation therapy.

Conclusions

Clinicians should consider the rare entity of true primary enteroliths associated with radiation enteritis in NTPSI cases with unknown etiologies.

Bile Salt Enterolith: An Unusual Etiology Mimicking Gallstone Ileus

Primary enterolithiasis is a relatively uncommon but important cause of small bowel obstruction. We present a case of a 69-year-old male with a history of laparoscopic Roux-en-Y gastric bypass and asymptomatic duodenal diverticulum diagnosed with small bowel obstruction. CT imaging showed an obstruction distal to the jejunojejunostomy, and surgical intervention was warranted. A 4.5 cm enterolith removed from the distal jejunum was found to contain 100% bile salts, consistent with a primary enterolith. Clinicians should retain a high index of suspicion for enteroliths as a cause of small bowel obstruction, especially if multiple risk factors for enterolith formation are present.