S5234 Afferent Loop Syndrome Presenting With Bowel Obstruction, Obstructive Jaundice, and Pancreatitis Managed by EUS-Guided Gastroenterostomy

Introduction: Afferent loop syndrome (ALS) is a rare complication following upper gastrointestinal tract reconstruction surgery, such as gastrojejunostomy or pancreaticoduodenectomy. It occurs from obstruction of the afferent limb, with potential causes including adhesions, malignancy, anastomotic strictures, or hernias. We present a unique case of ALS with bowel obstruction, obstructive jaundice, and pancreatitis, managed by endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with lumen-apposing metal stent (LAMS). Case Description: A 69-year-old woman with a Whipple resection for cholangiocarcinoma 3 years prior presented with abdominal pain, nausea, and vomiting. The patient had right upper quadrant tenderness on exam and elevated liver enzymes and lipase. Magnetic resonance imaging showed evidence of pancreatitis and an obstruction to the proximal blind-ending afferent limb distal to both the pancreatic jejunostomy and hepaticojejunostomy anastomoses. The intrahepatic and pancreatic ducts were dilated, but the hepaticojejunostomy anastomosis was patent, concerning for obstructed hepatobiliary limb. Push enteroscopy was pursued, but the endoscope could not be advanced beyond the strictured afferent limb. An EUS-GE was performed and LAMS was placed under endoscopic and fluoroscopic guidance with drainage of large amount of bile. Follow-up computed tomography (CT) showed LAMS in proper placement between the stomach and afferent limb and decreased dilation of the afferent limb. Patient’s bowel obstruction symptoms subsequently resolved, and her liver enzymes normalized. One month later, the patient’s symptoms returned, and a repeat esophagogastroduodenoscopy showed a dislodged LAMS in the stomach with similar CT scan findings of ALS. Subsequent EUS-GE was performed to place a LAMS (via transgastric approach) in the afferent limb, and the placement was confirmed via fluoroscopy. The LAMS was placed in the afferent limb, affixed to the stomach with endo sutures. Discussion: This case highlights a rare but significant presentation of ALS causing simultaneous small bowel obstruction, obstructive jaundice, and pancreatitis. Although each complication can occur independently, they rarely occur in combination. EUS-GE is a minimally invasive alternative to surgical bypass. However, stent migration can occur, as in our case, requiring repeat LAMS placement and suture affixation. More studies are needed to determine optimal intervention in such cases.