Candy Cane Roux Syndrome as a Cause of Obscure Abdominal Pain

Document Type

Article

Abstract

INTRODUCTION: Candy cane roux syndrome can present as an uncommon source of abdominal pain.

CASE DESCRIPTION/METHODS: A 49-year-old female with a past medical history of Roux-en-Y gastric bypass three years prior presented with progressively worsening sharp, left upper quadrant pain for two months. She had associated nausea and vomiting which worsened after food intake. The patient was admitted to the hospital for workup including a CT abdomen/pelvis and fluoroscopic swallow study which did not reveal any acute abnormalities. The gastroenterology service was consulted and performed an upper endoscopy out of concern for a marginal ulcer as the etiology for the patient’s pain.

Endoscopic findings revealed a normal esophagus, a 4 cm gastric pouch and no visible ulcers. Biopsies of the esophagus were notable for increased intraepithelial eosinophils, measuring > 20 per high power field. The patient was given a diagnosis of eosinophilic esophagitis and started on proton pump inhibitor therapy.

The patient continued to complain of similar abdominal pain despite medical therapy with proton-pump inhibitor and sucralfate. A repeat upper endoscopy was performed with biopsies to re-evaluate the initial diagnosis of eosinophilic esophagitis. During the exam, the afferent limb of the Roux-en-Y bypass was noted to be excessively long for which a diagnosis of candy cane syndrome was considered. The patient’s biopsies were found to have a higher prevalence of eosinophils in the distal versus proximal esophagus for which the previous diagnosis of eosinophilic esophagitis was dismissed.

The findings on EGD prompted a diagnostic laparoscopy which affirmed findings of an elongated afferent limb in candy cane configuration. The elongated limb was successfully revised without any immediate complications. On follow up with the patient two weeks later, the abdominal pain, nausea and vomiting had resolved.

DISCUSSION: Candy cane roux syndrome is an uncommon complication following Roux-en-Y gastric bypass wherein an excessively long afferent limb leads to symptoms including epigastric pain, nausea and vomiting. The pathophysiology is poorly understood, but has been attributed to dysmotility, dilation and possible bacterial overgrowth within the afferent limb. Diagnostic tests including CT, endoscopy and barium swallow have poor sensitivities ranging from 30-60% and are often unrevealing. Once the condition is diagnosed, surgical revision is often effective, with one case series reporting a 94% resolution of patients’ symptoms.

First Page

S1565

Last Page

S1566

DOI

10.14309/01.ajg.0000713944.67520.62

Publication Date

10-1-2020

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