Differential Diagnosis for Bilious Vomiting after Gastrectomy and Gastrojejunostomy

• Single most likely diagnosis:

  • Afferent loop syndrome: This condition is a common complication after gastrojejunostomy, especially when the afferent loop (the segment of intestine that carries bile and pancreatic juice to the stomach) is obstructed or kinked. The symptoms of bilious vomiting without food are classic for this condition, as the obstruction prevents the normal flow of bile into the stomach, causing it to accumulate and eventually be vomited.

• Other Likely diagnoses:

  • Efferent loop syndrome: Although less common than afferent loop syndrome, efferent loop obstruction can also occur, leading to vomiting. However, the vomit is typically not bilious in the early stages, making this a less likely diagnosis given the presence of bilious vomiting.
  • Gastrojejunostomy stenosis: Stenosis or narrowing of the gastrojejunostomy site can lead to vomiting, which may be bilious if the obstruction is significant enough to prevent normal intestinal flow.

• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.):

  • Intestinal ischemia or infarction: Although rare, ischemia or infarction of the intestinal segments used in the gastrojejunostomy can occur due to compromised blood supply. This is a medical emergency that requires prompt diagnosis and treatment to prevent severe morbidity and mortality.
  • Internal hernia: Internal hernias can occur through defects in the mesentery or other intestinal openings, potentially leading to obstruction and ischemia of the involved intestinal segment. This condition can be life-threatening if not recognized and treated promptly.

• Rare diagnoses:

  • Roux-en-Y stenosis: If a Roux-en-Y procedure was performed during the gastrojejunostomy, stenosis at the site of the anastomosis can occur, leading to obstructive symptoms.
  • Adhesions: Postoperative adhesions can cause bowel obstruction, leading to vomiting. However, the presence of bilious vomiting without food makes this a less likely cause in the immediate postoperative period following a gastrojejunostomy.