Mihir M. Shah, MD, Assar A. Rather, MD, Farrukh A. Khan, MD
General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA (Dr. Shah). General Surgery, Bayhealth General Surgery, Dover, DE, USA (Dr. Rather). General Surgery, Mercy Catholic Medical Center, Philadelphia, PA, USA (Dr. Khan).
Introduction: We report a case of intestinal obstruction secondary to intramural blood clots at the level of the jejunojejunostomy anastomosis, causing an acute elevation of bilirubin levels.
Case Description: A 71-year-old woman who had undergone cholecystectomy and Roux-en-Y hepaticojejunostomy presented to the emergency department with severe abdominal pain 1 day after discharge. She was afebrile and her vital signs were stable. Her abdomen was distended but soft. Her liver function test results were normal at the time of discharge. However, her total bilirubin was noted to be 2.3 mg/dL at the time of readmission, 1 week after the original reconstruction. Eight hours later, her total bilirubin increased to 8.5 mg/dL. A computed tomography (CT) scan revealed no bile leak but showed gross dilatation of the Roux limb and proximal small bowel and a collapsed distal small bowel. Re-exploration confirmed the CT scan findings. The proximal small-bowel limb was evacuated of the clots and the Roux limb decompressed. A CT scan obtained 4 weeks later showed resolution of the dilatation of the Roux limb and the proximal small bowel.
Discussion: Obstruction resulting from intramural blood clot formation in the small intestine is caused by inadequate hemostasis at the stapled anastomosis. Operative revision is rarely required. However, our patient had significant dilatation of the Roux limb and the small bowel, with a rapid elevation of serum bilirubin that required surgical exploration. Usually the cause is bleeding from the jejunojejunostomy, which may require reoperation and/or revision of the anastomosis.
Key Words: Intramural blood clots, Roux limb obstruction, Roux-en-Y hepaticojejunostomy, Bilirubin, Jejunojejunostomy