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Duodenojejunal intussusception: a rare occurrence Adult intussusceptions are uncommon with duodenojejunal intussusception being the rarest of all. The authors report a case of duodenojejunal intussusception in an adult patient secondary to an inflammatory fibroid polyp of the duodenum. A 35-year-old woman presented with melaena for 3 days with weakness. She had a history of easy fatiguability for the last 3 years and had received multiple blood transfusions in the past. There was no previous history of obvious upper gastrointestinal bleeding. There was no history of any abdominal pain, vomiting, anorexia and weight loss. Physical examination revealed marked pallor; laboratory investigations were unremarkable except for low haemoglobin (Hb) of 4.8 gm/dL. Abdominal examination was non-contributory. Previous upper gastrointestinal endoscopy (UGIE) performed elsewhere, during the course of evaluation for iron deficiency anaemia (Hb 8.7 gm/dL; microcytic hypochromic red blood cells), was reported as normal. Colonoscopy revealed a normal colon and rectum. She was taken for a contrast-enhanced computed tomography (CT) at our institute, which revealed an elongated duodenum with bowel-within-bowel appearance along the proximal jejunum suggesting a duodenojejunal intussusception, with a peripherally enhancing polypoidal mass lesion serving as the lead point (Fig. 1). A repeat UGIE confirmed the presence of a large polypoidal mass lesion in the third part of duodenum. At laparotomy, duodenojejunal intussusception was present, which reduced on handling. Duodenotomy revealed an ulcerated broad-based polyp from the second part (Fig. 2). A transduodenal polypectomy was performed and a diagnosis of an inflammatory fibroid polyp was confirmed on histopathology. Chronic hemorrhage from the large ulcerated polyp removed at surgery presumably was responsible for her chronic iron
deficiency anaemia. The patient remains well 6 months post-surgery with Hb of 12.8 gm/dL. Intussusceptions in adults are uncommon and mostly caused by tumours.1–3 Duodenojejunal intussusception is the rarest type of all because of the anatomical fixation of the duodenum, which precludes its telescoping into the jejunum.1,2 However, reports of duodenal tumours such as lipoma, adenoma and hamartomatous polyp have been described as lead points for duodenojejunal intussusceptions.1–6 The diagnosis is often challenging owing to its rarity and its chronic and non-specific clinical presentation.4,5 CT signs suggesting the diagnosis include an elongated duodenum with or without the typical target-like appearance in the proximal jejunum, with-or-without dislocation of the ampulla of Vater.6
References 1. Neogi P, Misra A, Agrawal R. Duodenal adenoma presenting as duodenojejunal intussusception. Acta Biomed. 2008; 79: 137–9. 2. Madanur MA, Mula VR, Patel D, Rathinaswamy A, Madanur AA. Periampullary carcinoma presenting as duodenojejunal intussusception: a diagnostic and therapeutic dilemma. Hepatobiliary Pancreat. Dis. Int. 2008; 7: 658–60. 3. Hwang CS, Chu CC, Chen KC, Chen A. Duodenojejunal intussusception secondary to hamartomatous polyps of duodenum surrounding the ampulla of Vater. J. Pediatr. Surg. 2001; 36: 1073–5. 4. Mourra N, Chafai N, Lewin M. An unusual cause of duodenojejunal intussusception and melena. Gastroenterology 2009; 137: e7–8. 5. Van Beers B, Trigaux JP, Pringot J. Duodenojejunal intussusception secondary to duodenal tumors. Gastrointest. Radiol. 1988; 13: 24–6.
Fig. 1. Coronal reconstructed computed tomography images (a, b) reveal an elongated duodenum (arrowhead) with a coiled-spring or target appearance along the proximal jejunum (black arrow). Also seen is a peripherally enhancing polypoidal mass acting as the lead-point (white arrow).
© 2013 Royal Australasian College of Surgeons
ANZ J Surg 83 (2013) 887–888
888
Images for surgeons
6. Choi SH, Han JK, Kim SH et al. Intussusception in adults: from stomach to rectum. AJR Am. J. Roentgenol. 2004; 183: 691–8.
Ankur Arora,* MD, DNB, FRCR, EDiR Vivek Mangla,† MS, MCh Amar Mukund,* MD Yashwant Patidar,* MD *Department of Radiodiagnosis, Institute of Liver & Biliary Sciences, New Delhi, India and †Department of HPB Surgery, Institute of Liver & Biliary Sciences, New Delhi, India doi: 10.1111/ans.12223
Fig. 2. Intraoperative photograph showing the polyp seen after duodenotomy. Figure in inset shows the broad based polyp delivered outside the duodenum through the duodenotomy.
© 2013 Royal Australasian College of Surgeons
Duodenojejunal intussusception: a rare occurrence Adult intussusceptions are uncommon with duodenojejunal intussusception being the rarest of all. The authors report a case of duodenojejunal intussusception in an adult patient secondary to an inflammatory fibroid polyp of the duodenum. A 35-year-old woman presented with melaena for 3 days with weakness. She had a history of easy fatiguability for the last 3 years and had received multiple blood transfusions in the past. There was no previous history of obvious upper gastrointestinal bleeding. There was no history of any abdominal pain, vomiting, anorexia and weight loss. Physical examination revealed marked pallor; laboratory investigations were unremarkable except for low haemoglobin (Hb) of 4.8 gm/dL. Abdominal examination was non-contributory. Previous upper gastrointestinal endoscopy (UGIE) performed elsewhere, during the course of evaluation for iron deficiency anaemia (Hb 8.7 gm/dL; microcytic hypochromic red blood cells), was reported as normal. Colonoscopy revealed a normal colon and rectum. She was taken for a contrast-enhanced computed tomography (CT) at our institute, which revealed an elongated duodenum with bowel-within-bowel appearance along the proximal jejunum suggesting a duodenojejunal intussusception, with a peripherally enhancing polypoidal mass lesion serving as the lead point (Fig. 1). A repeat UGIE confirmed the presence of a large polypoidal mass lesion in the third part of duodenum. At laparotomy, duodenojejunal intussusception was present, which reduced on handling. Duodenotomy revealed an ulcerated broad-based polyp from the second part (Fig. 2). A transduodenal polypectomy was performed and a diagnosis of an inflammatory fibroid polyp was confirmed on histopathology. Chronic hemorrhage from the large ulcerated polyp removed at surgery presumably was responsible for her chronic iron
deficiency anaemia. The patient remains well 6 months post-surgery with Hb of 12.8 gm/dL. Intussusceptions in adults are uncommon and mostly caused by tumours.1–3 Duodenojejunal intussusception is the rarest type of all because of the anatomical fixation of the duodenum, which precludes its telescoping into the jejunum.1,2 However, reports of duodenal tumours such as lipoma, adenoma and hamartomatous polyp have been described as lead points for duodenojejunal intussusceptions.1–6 The diagnosis is often challenging owing to its rarity and its chronic and non-specific clinical presentation.4,5 CT signs suggesting the diagnosis include an elongated duodenum with or without the typical target-like appearance in the proximal jejunum, with-or-without dislocation of the ampulla of Vater.6
References 1. Neogi P, Misra A, Agrawal R. Duodenal adenoma presenting as duodenojejunal intussusception. Acta Biomed. 2008; 79: 137–9. 2. Madanur MA, Mula VR, Patel D, Rathinaswamy A, Madanur AA. Periampullary carcinoma presenting as duodenojejunal intussusception: a diagnostic and therapeutic dilemma. Hepatobiliary Pancreat. Dis. Int. 2008; 7: 658–60. 3. Hwang CS, Chu CC, Chen KC, Chen A. Duodenojejunal intussusception secondary to hamartomatous polyps of duodenum surrounding the ampulla of Vater. J. Pediatr. Surg. 2001; 36: 1073–5. 4. Mourra N, Chafai N, Lewin M. An unusual cause of duodenojejunal intussusception and melena. Gastroenterology 2009; 137: e7–8. 5. Van Beers B, Trigaux JP, Pringot J. Duodenojejunal intussusception secondary to duodenal tumors. Gastrointest. Radiol. 1988; 13: 24–6.
Fig. 1. Coronal reconstructed computed tomography images (a, b) reveal an elongated duodenum (arrowhead) with a coiled-spring or target appearance along the proximal jejunum (black arrow). Also seen is a peripherally enhancing polypoidal mass acting as the lead-point (white arrow).
© 2013 Royal Australasian College of Surgeons
ANZ J Surg 83 (2013) 887–888
888
Images for surgeons
6. Choi SH, Han JK, Kim SH et al. Intussusception in adults: from stomach to rectum. AJR Am. J. Roentgenol. 2004; 183: 691–8.
Ankur Arora,* MD, DNB, FRCR, EDiR Vivek Mangla,† MS, MCh Amar Mukund,* MD Yashwant Patidar,* MD *Department of Radiodiagnosis, Institute of Liver & Biliary Sciences, New Delhi, India and †Department of HPB Surgery, Institute of Liver & Biliary Sciences, New Delhi, India doi: 10.1111/ans.12223
Fig. 2. Intraoperative photograph showing the polyp seen after duodenotomy. Figure in inset shows the broad based polyp delivered outside the duodenum through the duodenotomy.
© 2013 Royal Australasian College of Surgeons
