A path uncommonly traveled

A 48-year-old gentleman presented with abdominal pain for 1 year. He had undergone an abdominal surgery for recurrent abdominal pain 10 years back, details of which were not available. Clinical examination, blood chemistries and ultrasound were normal. He underwent esophagogastroduodenoscopy for evaluation of abdominal pain. Endoscopic examination revealed evidence of gastrojejunostomy with normal afferent and efferent loops. However since the duodenum was also normal and no evidence of gastric outlet obstruction noted, the endoscope was further negotiated into the duodenum after shortening the loop in the stomach. The endoscope could be negotiated into proximal jejunum and the site of gastrojejunostomy could be reached. The present image (Fig. 1) shows the view through the gastrojejunostomy site. The single arrow in the left lower corner shows the GE junction while the double arrow shows the pyloric opening. The endoscope can be seen from GE junction to the pylorus closely opposing the lesser curvature. The gastrojejunostomy site can be seen towards the right part of the image with tripe arrow pointing the opening of the efferent jejunal limb. Gastrojejunostomy (Bilroth II reconstruction) along with truncal vagotomy was a standard procedure for management of peptic ulcer disease in the pre proton pump inhibitor era [1]. However this procedure was generally done for complicated peptic ulcer disease, especially with gastric outlet obstruction. Hence we rarely can traverse the normal duodenum to reach the gastrojejunostomy site. Our case presents a unique image since the gastric outlet along with duodenum was normal