Vertigo And Bowel Surgery

Candida Bezoar
Figure 3.18. Gastric stump carcinoma. (A) Upper GI series demonstrating narrowing of the anastomosis with partial obstruction due to infiltrating carcinoma. (B) CT scan on the same patient showing irregular thickening of the anterior gastric wall.

Bezoars

Gastric and small-bowel bezoars are a well-recognized complication of Billroth I and II surgery, especially when a vagotomy has been performed [22,23]. Gastric bezoars are seen with both Billroth I and II, whereas small-bowel bezoars are generally seen after Billroth II. Phytobezoars, with the nidus usually composed of fruit and vegetable skins, seeds, and fibrous matter are most commonly found. Rarely fungus balls, generally composed of Candida, and less commonly Tory-lopsis glabrata, and concretions of antacids have been reported [24,25]. Bezoars may form shortly after surgery or many years later. Predisposing factors include loss of gastric enzymes and acid, gastric atony, decreased drainage, and improper mastication. Symptoms include early satiety, epigastric fullness, or symptoms related to gastric outlet obstruction. The diagnosis can be made on plain films, upper GI series, and CT images when mottled air collections trapped within the bezoar are identified (Figs. 3.19 and 3.20). A gastric bezoar will be freely

Bezors Stomach
Figure 3.19. Bezoar after Billroth II. (A) Coned-down view of the left upper quadrant showing a mottled mass containing air in the stomach due to a bezoar. (B) Upper GI series in the same patient.
Stomach Bezoar
Figure 3.20. Bezoar after vagotomy. Upper GI series showing a bezoar in the stomach after vagotomy alone.

movable, changing position with patient motion. Recently, an obstructing small-bowel bezoar after Billroth II was diagnosed on CT imaging [26]. Esophageal atony may develop after vagotomy, and subsequent esophageal foreign bodies may ensue (Fig. 3.21).

Figure 3.21. Esophageal foreign body after vagotomy. Upper GI series demonstrating a foreign body in the distal esophagus due to esophageal atony after vagotomy.

Intussusception and Prolapse

Intussusception after Billroth II surgery may be gastrojejunal or jejunogastric, with the jejunogastric form being more common. Acute and chronic forms exist. In the acute setting, which may be as soon as 4 days postoperatively, obstruction develops and surgery is required. The chronic form is usually intermittent and self-reducing.

In the jejunogastric form a characteristic striated filling defect or "coiled-spring pattern" is identified within the gastric remnant (Fig. 3.22). Both the efferent and afferent loops may intussuscept, with intussusception of the efferent limb accounting for approximately 75% of cases [27]. The gastrojejunal form typically shows gastric folds crossing the anastomosis into the proximal small bowel (Figs. 3.23 and 3.24). A degree of gastric outlet obstruction may be present. Incarceration may rarely develop, which would require immediate surgery.

Normal Upper Series Photos

Figure 3.22. Jejunogastric intussusception. (A) Upper GI series showing a smooth defect in the gastric remnant adjacent to the anastomosis due to jejunogastric intussusception. (B) Upper GI series in another patient showing the characteristic "coiled-spring" appearance in the gastric remnant.

Figure 3.22. Jejunogastric intussusception. (A) Upper GI series showing a smooth defect in the gastric remnant adjacent to the anastomosis due to jejunogastric intussusception. (B) Upper GI series in another patient showing the characteristic "coiled-spring" appearance in the gastric remnant.

Intussusception Jejunum
Figure 3.23. Gastrojejunal intussusception. (A) Upper GI series showing a smooth lobulated defect in the proximal jejunum due to gastrojejunal intussusception after Billroth II. (B) Coned-down view of the same patient.
Hemorrhagic Jejunum
Figure 3.24. Gastrojejunal intussusception. (A, B) Two views from an upper GI series showing a large smooth defect in the proximal jejunum due to intussusception.

Gastrojejunal or jejunogastric prolapse may be detected radiograph-ically as well [28]. Prolapse involves mucosa alone, whereas intussusception indicates full-thickness invagination. Prolapse may be asymptomatic or may be responsible for obstruction and possibly bleeding. A well-defined, usually lobulated defect is typically identified in the stomach or small bowel adjacent to the anastomosis (Fig. 3.25).

Dumping Syndrome

There are two types of dumping syndrome: early and late with respect to the time interval following a meal. The early dumping syndrome consists of postprandial sweating, flushing, palpitation, vomiting, diarrhea, weakness, and dizziness, often relieved by assuming a recumbent position. It is in part due to rapid emptying of the gastric remnant and can be seen with all types of gastric surgery that cause disruption or bypass of the normal pyloric sphincter mechanism and subsequent loss of the gastric reservoir function. Stomach size may also contribute to the development of the dumping syndrome. It is thought that symp-

Mmk 9IB

Figure 3.25. Jejunogastric prolapse. Upper GI series shows a well-defined defect in the gastric remnant due to prolapse.

toms result from premature passage of hyperosmolar chyme into the small bowel with subsequent increased extracellular fluid and distention of the bowel leading to autonomic and adrenal medullary corrective mechanisms. It has been suggested that a better term for this condition is "jejunal hyperosmolarity syndrome." About 5 to 10% of postgastrectomy patients develop clinical symptoms of this condition [29].

The radiographic diagnosis of the dumping syndrome is unreliable. Some studies have used physiological contrast material or barium glucose rather then barium alone in an attempt to identify rapid transit fluoroscopically; however, consistent results have not been obtained with this technique [12].

The late dumping syndrome refers to the occurrence of the early dumping symptoms 2 to 3 hours after a meal. The etiology is thought to be hypoglycemia secondary to postprandial hyperglycemia.

Afferent Loop Dysfunction

Afferent loop dysfunction may be acute or chronic. The term "acute afferent limb obstruction" has been used to refer to mechanical obstruction of the afferent limb, which may occur at any time following surgery. Herniation of the afferent loop through a surgical defect is the most common etiology [15]. On barium studies, the A limb fails to fill, although failure to fill the A limb does not necessarily indicate obstruction. CT images may be more reliable in establishing the diagnosis by showing the dilated afferent loop.

"Chronic afferent limb obstruction," or the afferent limb syndrome, refers to incomplete obstruction of the A limb, which may be due to stricture, tumor, adhesions, kinking at the anastomosis, internal hernia, intussusception, or recurrent ulcer in the A limb near the anastomosis. Preferential filling of the A limb may also lead to dilation of the A limb and is due to technical factors, such as restriction of the efferent (E) limb, especially with a left-to-right anastomosis accompanied by the Hofmeister procedure (restricted stoma), or inferior placement of the A limb on the greater curvature of the gastric remnant [12]. An unusually long A limb may predispose a patient to this condition as well. Partial obstruction of the A limb leads to stasis with accumulation of secretions and/or food, which may result in bacterial overgrowth and malabsorption. Postprandial fullness relieved by bilious vomiting is a characteristic frequent presentation.

Radiographic findings on barium study include dilatation of the A limb with retained secretions, and retention of barium on delayed films (Fig. 3.26). In some cases, preferential filling of the A limb may be observed, and examination in the upright position may accentuate this finding. CT imaging may also be diagnostic, demonstrating a characteristic dilated fluid-filled loop (Fig. 3.27). The CT appearance is somewhat variable, depending on the length of the A limb [30]. Confusion with cystic masses in the upper abdomen is possible if the surgical history is not appreciated and/or if contrast medium has not entered the A limb. Sonography may also show a similar pattern of cystic masses. Hepatobiliary imaging studies can also be used to make this diagnosis, by demonstrating persistent activity in the afferent loop [31]. An advantage of this technique over barium studies is the ability to fill the A limb via the liver.

Small Bowel Series Technique
Figure 3.26. Afferent limb syndrome. Supine view from an upper GI series after Billroth II shows marked dilatation of the afferent limb, which failed to empty well on delayed films owing to afferent limb syndrome from recurrent carcinoma.

Figure 3.27. Afferent limb syndrome. (A-C) Three films from a CT scan of the upper abdomen with oral and intravenous contrast media showing a markedly dilated fluid-filled af-ferent limb after Billroth II.

Figure 3.27. Afferent limb syndrome. (A-C) Three films from a CT scan of the upper abdomen with oral and intravenous contrast media showing a markedly dilated fluid-filled af-ferent limb after Billroth II.

Manual Strangulation
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