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CT of Acute Biliopancreatic Limb Obstruction

¹ Department of Radiology, Indiana University School of Medicine, UH 0279, 550 N University Blvd., Indianapolis, IN 46202.
² Department of Radiology, University Hospitals of Leicester, Leicester General Hospital, Leicester, LE5 4 PW, United Kingdom.
³ Department of Surgery, Indiana University School of Medicine, Indianapolis, IN 46202.

View larger version (51K): [in a new window]   Fig. 1A —Line diagrams showing anatomy after Whipple and gastric bypass surgery. Illustrations courtesy of Office of Visual Media, Indiana University Trustees, Indianapolis, IN. Anatomy after pylorus-preserving Whipple procedure in which cuff of duodenum is spared. Original Whipple procedure is shown (inset). Procedure entails radical dissection of pancreatic head, adjacent nodes, right half of omentum, gallbladder, common bile duct, and most or all of duodenum, followed by gastrojejunostomy/duodenojejunostomy, pancreaticojejunostomy, and hepaticojejunostomy. Position of pyloric sphincter is marked with PS.

View larger version (56K): [in a new window]   Fig. 1B —Line diagrams showing anatomy after Whipple and gastric bypass surgery. Illustrations courtesy of Office of Visual Media, Indiana University Trustees, Indianapolis, IN. Anatomy after Roux-en-Y gastric bypass surgery. Retrocolic version is shown. Note short afferent loop, usually less than 2.5 cm in length, at gastrojejunostomy (labeled afferent limb). Efferent loop of jejunum joins second much longer afferent loop (labeled duodenum) at jejunojejunostomy. Second afferent loop is biliopancreatic limb.

View larger version (126K): [in a new window]   Fig. 2A —49-year-old woman with Roux-en-Y gastric bypass surgery (patient 1 in Table 1). Images taken 12 days after surgery. Contrast-enhanced axial CT image of abdomen. Distention of duodenum (black arrow) is seen. Proximal biliopancreatic loop runs behind superior mesenteric vessels (white arrowheads).

View larger version (115K): [in a new window]   Fig. 2B —49-year-old woman with Roux-en-Y gastric bypass surgery (patient 1 in Table 1). Images taken 12 days after surgery. Distention of proximal jejunum (white arrows) is seen. Point of obstruction is at site of surgical clips (black arrowhead) close to midline. Obstructed loops are on right side.

View larger version (166K): [in a new window]   Fig. 2C —49-year-old woman with Roux-en-Y gastric bypass surgery (patient 1 in Table 1). Images taken 12 days after surgery. Coronal reformat. Distention of proximal jejunum is seen (white arrows).

View larger version (118K): [in a new window]   Fig. 3A —50-year-old man with previous pancreaticocystojejunosotmy (patient 5 in Table 1). Coronal reformat of contrast-enhanced CT. Course of obstructed biliopancreatic limb is well seen.

View larger version (106K): [in a new window]   Fig. 3B —50-year-old man with previous pancreaticocystojejunosotmy (patient 5 in Table 1). Axial image shows that loop (white arrow) lies anterior to mesenteric root containing branches of superior mesenteric vessels (black arrows). Note valvulae in obstructed loop (arrowheads). Transition point (not shown) was abrupt and adhesions were found on subsequent surgery.

View larger version (164K): [in a new window]   Fig. 4 —48-year-old woman (patient 2 in Table 1) with Roux-en-Y gastric bypass. Axial CT image obtained 1 day after surgery shows distended duodenum without significant wall thickening or enhancement (white arrow). More distant biliopancreatic limb shows wall enhancement and thickening (black arrows). There is edema of adjacent mesentery and blurred mesenteric vessels that are soft signs for bowel ischemia (white arrowhead). Surgery on same day showed necrosis with volvulus of biliopancreatic loop. Unlike in Figs. 2A, 2B, and 2C, distended loops are on left. Note pancreatic head (black arrowhead).

View larger version (150K): [in a new window]   Fig. 5A —64-year-old man with gastric cancer (patient 6 in Table 1). Coronal reformats of CT performed with IV but without oral contrast 2 days after Roux-en-Y esophagojejunostomy. Image shows possible benefit of using water rather than positive oral contrast in diagnosis of biliopancreatic limb obstruction. Obstruction was found at surgery to be intraluminal hematoma from bleeding vessel.

View larger version (147K): [in a new window]   Fig. 5B —64-year-old man with gastric cancer (patient 6 in Table 1). Distended biliopancreatic limb with high-density material (white arrows) is seen. Note distended common bile duct (arrowheads, A and B) and nondistended collapsed distal small bowel loops (black arrow).

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