Endoscopic management of afferent loop syndrome caused by enteroliths and anastomotic stricture. A case report

Afferent loop syndrome (ALS) is a rare complication of Billroth-II gastrojejunostomy. Causes of afferent loop obstruction include adhesions, internal hernias, intestinal strictures or malignancy. Obstruction caused by enteroliths is rare and usually requires surgery. We present the case of a 90-year-old man with a Billroth-II performed 50 years earlier and three acute pancreatitis. He presented with acute abdominal pain, without signs of pancreatitis. Upper digestive endoscopy revealed a punctiform anastomotic stricture of the afferent loop. Fluoroscopy-guided contrast injection showed a dilated loop with multiple filling defects. After through-the-scope balloon dilation, multiple calculi similar to gallstones were observed in the afferent loop and were removed with a basket. There were no signs of choledochoduodenal fistula or abnormalities in the ampulla of Vater, leading us to assume the formation of intestinal calculi. This case represents a rare cause of ALS, emphasizing the possibility of solely endoscopic treatment. The stone was removed and the anastomotic stricture which was the underlying cause of the enterolith formation was treated by endoscopy. Endoscopic management of enterolith-related ALS is technically difficult and rarely reported. To our knowledge, there are two cases in which electrohydraulic lithotripsy was used to fragment a large enterolith in the afferent loop. This includes one report of failed endoscopic retrieval of an enterolith and in another case a perforation after an attempt to grasp the stone with a basket. ALS has multiple causes and non-specific clinical manifestations. We highlight the importance of high clinical suspicion and individualized treatment according to the patient's condition, severity, ALS etiology and locally available treatment possibilities.