A 55-year-old man who underwent Billroth II gastrectomy two years ago presents with colicky upper abdominal pain beginning 20 minutes after meals, followed by bilious vomiting that relieves the pain. Abdominal examination shows a soft, mildly tender mass in the right upper quadrant. What is the most likely diagnosis?

• A Roux stasis syndrome
• B Efferent loop obstruction
• C Alkaline reflux gastritis
• D Afferent loop syndrome ✓

Explanation

In afferent loop syndrome after Billroth II, the afferent limb carrying bile and pancreatic juice becomes obstructed, causing postprandial colicky pain relieved by sudden bilious vomiting, sometimes with a palpable right upper quadrant mass. Alkaline reflux gastritis causes continuous burning epigastric pain with bilious vomiting but without the colicky pain-vomiting-relief sequence or mass, which distinguishes it from the key.

Reference: Sabiston Textbook of Surgery, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.