Postoperative Intestinal Lesions

Except for Billroth I and II reconstructive operations, surgically anastomosed intestine is rarely accessible to endoscopy. Because double-balloon endoscopy allows support of any portion of the intestine and advancement of the endoscope in any direction, it enables observation of the afferent loop after Roux-en-Y anastomosis through which food does not pass and permits insertion against peristalsis. It allows observation of the bypassed and nonbypassed intestinal tracts as needed. In contrast, the antiperistaltic afferent loop and bypassed intestinal tracts cannot be observed with a capsule endoscope because it is not manipulable. Double-balloon endoscopy facilitates observation of the intestine that is otherwise inaccessible, which is expected to elucidate previously unknown pathological conditions in the postoperative intestine.

This subsection describes our experience: a case of multiple ulcers associated with blind loop syndrome occurring in the afferent loop after Roux-en-Y reconstruction and a case of adhesive intestinal obstruction in which the adhesion between the small intestine and the abdominal wall was successfully identified.

The blind loop syndrome, one of the malabsorption syndromes, is a collective name for pathological conditions manifesting as diarrhea, dyspepsia, malabsorption, and anemia that are caused by abnormal growth of intestinal bacterial flora associated with abnormal retention of intestinal contents in the intestinal tract [1]. Evidence suggests that the anemia in this syndrome is due to vitamin B12 deficiency, which may be caused by the use of vitamin B12 by intestinal bacteria and the binding of intestinal bacteria to the intrinsic factor-vitamin B12 complex.

A woman underwent cholecystectomy, choledochojejunostomy, and subtotal gastrectomy for organ damage due to a traffic accident at the age of 33 years. She began to have intermittent melena at age 40 years and was assigned a diagnosis of severe anemia. For investigation of the source of bleeding, she was admitted to our hospital and underwent double-balloon endoscopy at age 42. A long duodenal afferent loop was anastomosed to the jejunum by means of a Roux-en-Y anastomosis. Slightly longitudinal multiple ulcers were found in the afferent loop (Fig. 10.5.1a,b). Some of the ulcers were associated with oozing bleeding. These ulcers were found throughout the long afferent loop. Abnormal growth of intestinal bacterial flora in the blind loop was believed to be involved in the ulceration, and metronidazole (Flagyl) was given. Double-balloon endoscopy after 1 month of treatment showed an improvement in the ulcers with many scars (Fig. 10.5.1c,d). The primary cause of her anemia appeared to be chronic bleeding from multiple ulcers in the blind loop. This case suggests that potential multiple ulcers should be taken into consideration as a cause of anemia in patients with blind loop syndrome.

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