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Blind Loop Syndrome

Blind loop syndrome is a complication of Billroth II gastrectomy and gastroenterostomy or other end-to-end or end-to-side bowel anastomosis consisting of dilatation of a bypassed intestinal loop, that becomes excluded from normal intestinal transit. This can lead to stasis, bacterial population overgrowth, mucosal ulceration, short bowel syndrome, and malabsorption.


Presentation

Blind loop syndrome patients presents with non-specific symptoms, such as nausea, lack of appetite, dyspepsia, flatulence, abdominal distention and pain, early satiety, diarrhea, steatorrhea, unintentional weight loss eventually leading to cachexia and nutrient deficiencies, such as vitamin B12, leading to megaloblastic anemia [1] or protein deficiency due to steatorrhea and malabsorption, causing peripheral edema [2]. In children, the physician will notice growth retardation. Although these findings are caused by due to different etiologies, in this case, they are due to the loss of defense mechanisms in the by-passed intestinal loop [3] [4] and to the decreased absorption surface. A high level of suspicion should be raised in the patients who underwent abdominal surgery, especially gastroenterostomy or Billroth II gastric resection.

Symptoms develop gradually, over a long period of time and also consist of other vitamin deficiency signs, such as blepharitis, glossitis, and cheilosis, neurologic abnormalities: decreased proprioception and deep tendon reflexes [5] and additional digestive signs, like bilious vomiting [5], caused by convulsive emptying of the blind loop.

Easy Bruising
  • Vitamin K deficiency causing easy bruising and spontaneous bleeding. Aetiology Surgery - eg, Billroth's operation II, Roux-en-Y procedure, gastric bypass for obesity. Inflammatory bowel disease - eg, Crohn's disease. Scleroderma.[patient.info]
Steatorrhea
  • Ingestion of an excess of fat leads to steatorrhea. As a side-effect, malabsorption of iron, calcium and other elements can occur causing anemia and hypocalcemia. The blind loop syndrome gives the same symptoms.[ncbi.nlm.nih.gov]
  • […] nutrient deficiencies, such as vitamin B12, leading to megaloblastic anemia or protein deficiency due to steatorrhea and malabsorption, causing peripheral edema.[symptoma.com]
  • This results in problems inclusive of but not restricted to vitamin B12 deficiency, fat malabsorption and steatorrhea, fat-soluble vitamin deficiencies and intestinal wall injury.[en.wikipedia.org]
Abdominal Distension
  • Abdominal examination may reveal cachexia, abdominal distension and evidence of vitamin and mineral deficiencies. Investigations SIBO can be diagnosed by: [ 5 ] Culture of jejunum aspirate for bacterial counts. 14C-D-xylose breath testing.[patient.info]
  • My primary symptoms were chronic constipation and bloating or abdominal distension no matter what I ate. After the first round I felt great...better than I had felt in months. Then the symptoms returned. #8 Xifaxan didn't do shit for me.[bariatricfacts.org]
  • The patient complained of abdominal distension and had an abnormal serum biochemistry caused by blind loop syndrome related to childhood abdominal surgery.[ekjm.org]
Intestinal Disease
  • From Wikidata Jump to navigation Jump to search intestinal disease characterized by a dysbalance of the bacterial flora of the small intestine, causing derangement to the normal physiological processes of digestion and absorption Bacterial overgrowth[wikidata.org]
Night Blindness
  • As such, lack of vitamin (A) causes night blindness, for example, and low levels of vitamin (D) may lead to weakened bones because it affects the body's capacity to absorb calcium.[epharmapedia.com]
  • Severe SIBO with fat malabsorption may be associated with reduced absorption of fat-soluble vitamins: Vitamin A: dry eyes, night blindness Vitamin D: osteomalacy with bone fractures, decreased calcium absorption, resulting in increased oxalate absorption[nutrientsreview.com]
Blepharitis
  • Symptoms develop gradually, over a long period of time and also consist of other vitamin deficiency signs, such as blepharitis, glossitis, and cheilosis, neurologic abnormalities: decreased proprioception and deep tendon reflexes and additional digestive[symptoma.com]
Decreased Proprioception
  • Symptoms develop gradually, over a long period of time and also consist of other vitamin deficiency signs, such as blepharitis, glossitis, and cheilosis, neurologic abnormalities: decreased proprioception and deep tendon reflexes and additional digestive[symptoma.com]
Convulsions
  • […] period of time and also consist of other vitamin deficiency signs, such as blepharitis, glossitis, and cheilosis, neurologic abnormalities: decreased proprioception and deep tendon reflexes and additional digestive signs, like bilious vomiting, caused by convulsive[symptoma.com]

Workup

The first step in diagnosing blind loop syndrome is to do an abdominal radiograph, which will show a nonspecific gas collection; this aspect may be absent if the loop is not empty. Barium fluoroscopy may bring additional information in this case, as well as exclude intestinal diverticulosis or strictures. Thus, barium can enter a limited portion of the afferent loop, not enter it at all or enter and then be propelled back into the stomach [1].

A computer tomography will help observe the anastomosis and an adjacent dilated intestinal loop, that may be filled with feces, leading to a difficult imaging differential diagnosis with small bowel obstruction or abscess [6]. Abdominal computer tomography and computer tomography enterography also provide information about neighboring structures, such as the pancreas.

Hydrogen breath test is used to measure the level of exhaled hydrogen; if high, this suggests carbohydrate maldigestion and bacterial overgrowth syndrome, a complication of the blind loop. This can also be diagnosed using D-xylose breath test, that measures the exhaled carbon dioxide level.

Steatorrhea dictates the need for a quantitative fecal test, also an indicator of small intestinal bacterial overgrowth syndrome, chronic pancreatitis or short bowel syndrome. Bile acid breath test can also be performed, in order to identify bile dysfunction. If small intestinal bacterial overpopulation is still uncertain at this point, a small intestinal aspirate and culture need to be performed, having in mind that this is the diagnosis gold standard in this instance.

Absorption of various nutrients being impaired in blind loop syndrome, various malabsorption diagnosis techniques has been developed. Co60-tagged vitamin B12 urinary and fecal excretion and hepatic uptake are examples of these methods [7] [8] [9]. If urinary vitamin B12 is diminished, the test is repeated after intrinsic factor is administered. If urinary excretion becomes normal, the diagnosis is pernicious anemia, probably caused by gastric atrophy, and blind loop syndrome is disproved. Gastric fluid analysis and gastric biopsy may also be helpful in certain cases.

Macrocytic Anemia
  • Vitamin B12 deficiency may cause macrocytic anemia in which the average size of erythrocytes is larger than normal. Bacterial growth may also cause inflammation in the intestinal walls and this impairs the absorption of carbohydrates and protein.[natural-homeremedies.org]
  • anemia, peripheral neuropathy Iron Microcytic anemia Calcium Muscle twitching (tetany) Selenium Dermatitis Chart sources: [1,4] SIBO Complications A.[nutrientsreview.com]
  • The experimental production of macrocytic anemia by operation of the intestinal tract. Blood 1949; 4:803–815. 4. Kim TH, Kim JK, Song SY, et al. A case of amyloidosis associated with malignant lymphoma, presenting as a Malabsorption syndrome.[ekjm.org]
Pseudomonas
  • The remaining healthy man showed an overgrowth of E. coli and Pseudomonas (P) aeruginosa, but the species did not have the ability of deconjugation.[ncbi.nlm.nih.gov]

Treatment

  • Tetracyclines have been the mainstay of treatment for BLS, but recent studies have concluded Rifaximin to be very effective in the treatment of BLS.[en.wikipedia.org]
  • Treatment: Intermittent or continuous antibiotic treatment is the first-line therapy. In addition vitamin B 12 replacement is required.[doi.org]
  • Biliopancreatic diversion (BPD) according to Scopinaro's method is a safe and effective technique for treatment of morbid obesity. In this operation a side-to-side enteroenterostomy is created 60 cm proximal to the ileocecal valve.[ncbi.nlm.nih.gov]
  • However, the BLS is not always reversible that is why some treatment options focus on getting rid of bacterial overgrowth and correcting nutritional deficiencies.[syndromespedia.com]
  • The only curative option for treatment of blind loop syndrome is surgical repair. Without surgical repair, treatment is aimed at reducing symptoms from blind loop syndrome.[adventistmedicalgroup.org]

Prognosis

  • […] distended segment of bowel at the anastomosis surgical clips are usually adjacent to the pouch pouch may be filled with fluid or fecal material A blind loop or blind pouch may be misinterpreted as an abscess or small bowel obstruction Treatment and prognosis[radiopaedia.org]
  • Prognosis A lot of patients are cured completely with antibiotics. If surgical treatment is needed per evaluation, it can have a very good prognosis outcome.[syndromespedia.com]
  • Prognosis This will depend on the cause, severity and associated complications.[patient.info]
  • Support Groups These resources can provide more information on Menkes syndrome: National Organization for Rare Disorders -- rarediseases.org/rare-diseases/menkes-disease NIH/NLM Genetics Home Reference -- ghr.nlm.nih.gov/condition/menkes-syndrome Outlook (Prognosis[mclaren.org]

Etiology

  • These studies demonstrate (a) significant protein loss as one etiologic factor for protein metabolic disturbances in the human and experimental rat blind-loop syndrome, (b) the occurrence of intestinal protein loss as a manifestation of functionally significant[ncbi.nlm.nih.gov]
  • Although these findings are caused by due to different etiologies, in this case, they are due to the loss of defense mechanisms in the by-passed intestinal loop and to the decreased absorption surface.[symptoma.com]
  • Small intestinal bacterial overgrowth is a probable etiology in malnutrition in older people who have undergone partial gastrectomy.[karger.com]
  • Roux and coworkers coined the term afferent loop syndrome in 1950. [11] The first detailed description in the English literature of the etiology, clinical presentation, and treatment of ALS was contributed by Wells and Welbourn in 1951. [12] Etiology[emedicine.medscape.com]
  • Etiology Exogenous risk factors Diet rich in nitrates and/or salts (e.g., dried, preserved food) Nicotine use Low socioeconomic status Obesity (for cancers of the gastroesophageal junction) Endogenous risk factors Diseases associated with a higher risk[amboss.com]

Epidemiology

  • Epidemiology Sex : Peak incidence : 70 years Geographical distribution : strong regional differences High incidence in South Korea and Japan Declining incidence in the United States and Europe References: [1] [2] Epidemiological data refers to the US,[amboss.com]
  • Peptic ulcer surgery during the H2-receptor antagonist era: a population-based epidemiological study of ulcer surgery in Helsinki from 1972 to 1987. Br J Surg. 1991 Jan. 78(1):28-31. [Medline]. Tovey FI, Godfrey JE, Lewin MR.[emedicine.medscape.com]
Sex distribution
Age distribution

Pathophysiology

  • PAK Major progress has been made in the pathophysiologic elucidation and management of nephrolithiasis during the past two decades.[books.google.com]
  • Current concept of pathophysiology. Surgery 73: 639, 1973 Google Scholar 6. Bayes BJ, Hamilton TR: Blind loop syndrome in children with malabsorption secondary to intestinal anastomosis Arch Dis Child 44: 76, 1969 PubMed CrossRef Google Scholar 7.[link.springer.com]
  • Pathophysiology Obstruction to the normal passage of food through the affected segment leads to ineffective bile salt digestion of fats and fat-soluble vitamins.[patient.info]
  • […] of gastrointestinal obstruction Partial gastrectomies may be used in exceptional cases References: [14] Complications Malignant acanthosis nigricans A paraneoplastic syndrome seen in adenocarcinomas of GI origin, especially in gastric adenocarcinoma Pathophysiology[amboss.com]
  • The pathophysiology and signs and symptoms associated with ALS result from partial or complete obstruction of the afferent loop.[emedicine.medscape.com]

Prevention

  • This prevents fat and fat-soluble vitamins from being absorbed into the body. It also leads to fatty stools. Vitamin B12 deficiency may occur because the extra bacteria that form in the blind loop use up this vitamin.[nlm.nih.gov]
  • It is now possible to detect the cause of stone disease in more than 95% of patients, to prevent recurrent formation of stones in the majority of patients, and to remove most existing stones less invasively.[books.google.com]
  • The overgrowth of bacteria in the small intestine is prevented by various mechanical and chemical factors which include the constant peristaltic movement of contents along the length of the gastrointestinal tract and the antibacterial properties of gastric[en.wikipedia.org]
  • To aid in preventing bacterial resistance to drugs, doctors try to mix and switch among medications.[epharmapedia.com]

References

Article

  1. Goldstein F, Wirts C, Kramer S.The relationship of afferent limb stasis and bacterial flora to the production of postgastrectomy steatorrhea. Gastroenterology. 1961;40():47-55.
  2. Naish J, Capper W. Intestinal cul-de-sac phenomena in man. Lancet. 1953;265(6786):597-600.
  3. Elphick DA, Chew TS, Higham SE, Bird N, Ahmad A, Sanders DS. Small bowel bacterial overgrowth in symptomatic older people: can it be diagnosed earlier? Gerontology. 2005;51:396–401.
  4. Iivonen MK, Ahola TO, Matikainen MJ. Bacterial overgrowth, intestinal transit, and nutrition after total gastrectomy. Comparison of a jejunal pouch with Roux-en-Y reconstruction in a prospective random study. Scand J Gastroenterol. 1998;33:63–70.
  5. Adams J. Postgastrectomy megaloblastic anaemia and the loop syndrome.Gastroenterologia. 1958; 89(5-6):326-30
  6. Sandrasegaran K, Maglinte DD, Rajesh A, et al. CT findings for postsurgical blind pouch of small bowel. AJR Am J Roentgenol. 2006;186 (1): 110-113.
  7. Heinle R, Welch A, Scharf V, et al. Studies of excretion (and absorption) of Co60 labeled vitamin B12 in pernicious anemia. Trans Assoc Am Physicians. 1952; 65():214-222
  8. Glass G, Boyd L, Stephanson L. Intestinal absorption of vitamin B12 in humans as studies by isotope technic. Proc Soc Exp Biol Med. 1954;86(3):522-526.
  9. Schilling R. Intrinsic factor studies II. The effect of gastric juice on the urinary excretion of radioactivity after the oral administration of radioactive vitamin B12. J Lab Clin Med. 1953;42(6):860-866.

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Last updated: 2019-06-28 11:24