Presentation
The patient presented with severe diffuse abdominal pain more centered at the central region that gradually progressed over one week. On examination, the abdomen was tender and rigid. Laboratory tests revealed leukocytosis and elevated liver and pancreatic enzymes. The patient gave a history of bariatric surgery 10 years ago.
Patient Data
Abdominal computed tomography (CT) was performed with oral gastrografin and intravenous contrast. Two small bowel limbs were identified; one of the limbs (that was seen connecting the partially resected stomach to the colon) showed no evidence of obstruction, and oral contrast was seen opacifying these segments and reaching the colon, in keeping with the alimentary limb of biliopancreatic diversion. The other limb that showed a proximal blind duodenal stump that remained un-opacified by oral contrast was significantly fluid-distended and exhibited abrupt transition along its distal segment at the right lower abdomen, indicating obstructed biliopancreatic limb. Mild dilatation of biliary channels and pancreatitis-related changes were noted, likely due to pancreatic-biliary stasis. Mild abdominopelvic ascites. A diagnosis of the obstructed biliopancreatic limb due to adhesion or anastomotic stenosis was made with associated changes of biliary stasis and acute pancreatitis.
Figure 1: dilated fluid-filled 2nd part of duodenum forming a proximal segment of biliopancreatic limb (black arrow) along with dilated jejunal loops (4-point star) not opacified by oral contrast. Mildly dilated common bile duct (white arrow) and prominent right and left hepatic ducts.
Figure 2: small volume partially resected contrast opacified stomach (white filled arrow) Dilated duodenal stump closed by clips (white hollow arrow), distended fluid-filled loops of biliopancreatic limb (6-point star), contrast filled small bowel loops of alimentary limb (black filled arrow) with no signs of obstruction and free passage of contrast into colon till recto-sigmoid bowel (5-point star). Transition point (black hollow arrow) close to anastomosis site of the biliopancreatic limb with possible adjacent culprit adhesions.
Figure 3: pancreatic edema and peri-pancreatic fluid collection(arrow).
Case Discussion
Operative findings confirmed imaging diagnosis of biliopancreatic limb obstruction due to adhesions close to the anastomotic site. Adhesiolysis was done, obstruction to the biliopancreatic limb was released, and a change in color of these affected bowel segments from dusky to pink was observed. The alimentary loop was found normal in caliber and color.
In conclusion, obstruction of the biliary pancreatic limb due to adhesions or anastomosis site stenosis is an important late complication of biliopancreatic diversion type of bariatric surgical procedure and requires immediate imaging evaluation by appropriate radiological examination and may warrant immediate surgical intervention due to potentially high risks of bowel ischemia and perforation as well as acute pancreatitis and sepsis. Radiologists and clinicians should be aware of such entities and appropriate imaging approaches to reach a conclusive diagnosis.
Acknowledgement: Special thanks to Dr Muhammad Zia Ul Hassan (Consultant Radiologist) and Dr Khawaja Bilal Waheed (Consultant Radiologist) for contributing to the case.