E4928. Intraluminal Blood Clot at Jejunojejunal Anastomosis After Total Gastrectomy and Roux-En-Y Reconstruction Presenting as Coffee-Ground Emesis
Authors
Justin Chen;
SUNY Upstate Medical University
William Lee;
Rutgers - New Jersey Medical School
Douglas Ardekani;
Rutgers - New Jersey Medical School
Inessa Goldman;
Rutgers - New Jersey Medical School
Background
Small bowel obstruction (SBO) is a well-documented complication of laparoscopic Roux-en-Y gastric bypass (LRYGB). However, the development of an intraluminal blood clot is a rare postoperative cause of SBO in these patients that is not commonly documented. Given the infrequency of such cases, there is currently no established treatment algorithm. Operative management with enterotomy has been previously reported in the literature. This case illustrates an unusual presentation of SBO secondary to intraluminal blood clot with coffee-ground emesis that was managed nonoperatively with EGD. We believe this is the first reported instance of nonoperative management of jejunojejunal obstruction (JJO) presenting as coffee-ground emesis after total gastrectomy and Roux-en-Y reconstruction.
Educational Goals / Teaching Points
1. Review LRYGB and relevant gastrointestinal anatomy. 2. Appreciate imaging findings of SBO in patients after Roux-en-Y gastric bypass. 3. Understand possible complications of SBO in patients s/p LRYGB, such as afferent loop syndrome. 4. Discuss treatment options available for management of intraluminal blood clot at jejunojejunal anastomosis.
Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
CT of the abdomen and pelvis with IV contrast showed fluid-filled distention of the pancreaticobiliary (afferent) limb and jejunal Roux (efferent) limb. Intraluminal hyperdensity and hematocrit level were noted in the left mid-abdominal jejunal loops, which was confirmed to represent a large intraluminal blood clot on subsequent endoscopic evaluation. Marked decompression of small bowel was noted distal to the JJA. This was the first case of intraluminal blood clot at jejunojejunal anastomosis presenting as coffee-ground emesis with no stigmata of recent bleeding found in the distal esophagus on EGD.
Conclusion
SBO secondary to intraluminal blood clot after total gastrectomy and Roux-en-Y reconstruction is a rare phenomenon that is sparsely documented in the literature. Dilation of both the afferent and efferent limb postoperatively should raise suspicion for possible intraluminal blood clot. Due to the infrequency of such cases, there is no established treatment algorithm. This case illustrates that EGD may be a viable diagnostic and therapeutic modality for patients after LRYGB or Roux-en-Y obstruction who present with coffee-ground emesis and acute anemia.
