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Jejunogastric intussusception: a rare cause of gastric outlet obstruction A 55-year-old male patient was admitted to the emergency department with complaints of severe colicky epigastric pain, bilious vomiting and haematemesis over the previous 2 days. The patient’s medical history indicated that gastrojejunostomy (Billroth II reconstruction) surgery was performed about 15 years before to correct a duodenal ulcer, and he admitted that he had not experienced any serious dyspeptic complaints thereafter. Abdominal examination revealed a painful mass in the epigastric region with palpation. The patient’s blood pressure was 120/70 mmHg and his pulse was 88 bpm. Laboratory investigations revealed that the haemoglobin (8.2 g/dL), white blood cell count (14.000/μL), and coagulation tests were within normal range. A solid mass covered with blood, fibrin, and food residues was observed during gastroscopy, and occupied a large part of the stomach (Fig. 1). Initially, haemorrhagic gastric tumor was considered. Contrast-enhanced abdominal tomography showed a heterogeneous mass consisting of loops of the small bowel inside the enlarged stomach (Fig. 2). Laparotomy was performed to confirm a diagnosis of jejunogastric intussusception (JGI). During laparotomy, we saw that part of the afferent loop ranging from 5-cm distal to the Traitz ligament to the gastrum and part of the efferent limb of the jejunum were nutritionally impaired. We also observed that parts of both of the afferent and efferent loops were intussuscepted into the stomach (type 3). Following gastrotomy from the anterior face near the large curvature, intussuscepted gangrenous jejunal limbs forming a mass in the gastric lumen were observed. We resected the intussuscepted bowel segment, nutritionally impaired segment of the afferent loop, and part of the gastrum
Fig. 1. Gastric endoscopy showed a lobulated congestive mass in the body of the stomach.
© 2013 Royal Australasian College of Surgeons
containing the intussuscepted segments, and performed a Rouxand-Y gastrojejunostomy (Fig. 3). No pathologic finding, apart from necrosis, was observed on pathologic examination of the invaginated segment. The patient was discharged on the 8th postoperative day without complication. JGI is a rare complication of partial gastrectomy or gastrojejunostomy (0.15%).1 Early diagnosis and urgent surgical intervention is essential, because a delay in treatment of more than 48 h, following onset of severe symptoms in these cases is associated with a rise of mortality rate from 10% to 50%.2,3 JGI has been described in two clinical forms, acute and chronic. In the acute form, strangulation and incarceration are encountered more frequently. The most notable complaints are severe epigastric pain, vomiting and haematemesis. In the chronic form, spontaneous reductions are seen. Therefore, complaints are not severe and accurate diagnosis is quite difficult.1,4 Gastroscopy may help in diagnosis, however, in the presence of blood, the appearance of the intussuscepted bowel loops may resemble a bleeding gastric tumour.5 In the acute form of the disease and also during the symptomatic period of the chronic form of the disease,3 the contrastenhanced abdominal tomography may show a dilated stomach with intragastric filling by bowel loops.3,6 Three anatomic types of JGI have been described: intussusception of the afferent loop (type 1), efferent loop (type 2) and both loops
Fig. 2. Contrast-enhanced abdominal tomography showing a dilated stomach with intragastric non-homogeneous mass compatible with bowel loops (arrow).
ANZ J Surg 84 (2014) 191–192
192
Images for surgeons
Acknowledgments This study was carried out in Rize University Surgery Department, with the permission of the Department. Dr Pergel is the guarantor for this paper, and takes responsibility for the integrity of the work as a whole.
References
Fig. 3. Intussuscepting bowel segment is delivered out of the gastrotomy incision (black arrow; stomach, white arrow; intussuscepted jejunal segment).
together (type 3). Type 2 is most commonly encountered, accounting for 80% of cases.7 Although the causes of JGI are not clearly defined, factors such as long afferent loop, abnormal motility, hyperacidity, retrograde peristaltism and sudden increase in intra-abdominal pressure have been proposed.5,8 In conclusion, JGI must be considered in the differential diagnoses of patients who have a history of previous gastric surgery along with severe epigastric pain, vomiting, haematemesis or palpable epigastric mass. Particularly in haemorrhagic cases, endoscopic findings may be similar to those for gastric cancer.
1. Waits JO, Beart RW, Charboneau JW. Jejunogastric intussusception. Arch. Surg. 1980; 115: 1449–52. 2. Achyut JM, Ishwar JM, Jayantkumar BD et al. Jejunogastric intussusception: case report and review of the literature. Dig. Endosc. 2004; 16: 88–90. 3. Archimandritis AJ, Hatzopoulos N, Hatzinikolaou P et al. Jejunogastric intussusception presented with hematemesis: a case presentation and review of the literature. BMC Gastroenterol. 2001; 1: 1. 4. Foster DG. Retrograde jejunogastric intussusception; a rare cause of hematemesis. review of the literature and report of two cases. AMA Arch. Surg. 1956; 73: 1009–17. 5. Rather SA, Dar TI, Wani RA, Khan A. Jejunogastric intussusception presenting as tumor bleed. J. Emerg. Trauma Shock 2010; 3: 406–8. 6. Zenooz NA, Holz SP, Robbin MR. Jejunogastric intussusception: a case report with the review of literature. Emerg. Radiol. 2007; 13: 265–7. 7. Reyelt WP, Anderson AA. Retrograde jejunogastric intussusception. Surg. Gynecol. Obstet. 1964; 119: 1305–11. 8. Kim KH, Jang MK, Kim HS et al. Intussusception after gastric surgery. Endoscopy 2005; 37: 1237–43.
Ahmet Pergel,* MD Remzi Adnan Akdogan,† MD Ibrahim Aydin,* MD Ahmet Fikret Yucel,* MD Ibrahim Sehitoglu,‡ MD Dursun Ali Sahin,* MD Departments of *Surgery and †Gastroenterology, School of Medicine, Rize University, and ‡Department of Pathology, Rize Educational and Research Hospital, Rize, Turkey doi: 10.1111/ans.12229
© 2013 Royal Australasian College of Surgeons
Jejunogastric intussusception: a rare cause of gastric outlet obstruction A 55-year-old male patient was admitted to the emergency department with complaints of severe colicky epigastric pain, bilious vomiting and haematemesis over the previous 2 days. The patient’s medical history indicated that gastrojejunostomy (Billroth II reconstruction) surgery was performed about 15 years before to correct a duodenal ulcer, and he admitted that he had not experienced any serious dyspeptic complaints thereafter. Abdominal examination revealed a painful mass in the epigastric region with palpation. The patient’s blood pressure was 120/70 mmHg and his pulse was 88 bpm. Laboratory investigations revealed that the haemoglobin (8.2 g/dL), white blood cell count (14.000/μL), and coagulation tests were within normal range. A solid mass covered with blood, fibrin, and food residues was observed during gastroscopy, and occupied a large part of the stomach (Fig. 1). Initially, haemorrhagic gastric tumor was considered. Contrast-enhanced abdominal tomography showed a heterogeneous mass consisting of loops of the small bowel inside the enlarged stomach (Fig. 2). Laparotomy was performed to confirm a diagnosis of jejunogastric intussusception (JGI). During laparotomy, we saw that part of the afferent loop ranging from 5-cm distal to the Traitz ligament to the gastrum and part of the efferent limb of the jejunum were nutritionally impaired. We also observed that parts of both of the afferent and efferent loops were intussuscepted into the stomach (type 3). Following gastrotomy from the anterior face near the large curvature, intussuscepted gangrenous jejunal limbs forming a mass in the gastric lumen were observed. We resected the intussuscepted bowel segment, nutritionally impaired segment of the afferent loop, and part of the gastrum
Fig. 1. Gastric endoscopy showed a lobulated congestive mass in the body of the stomach.
© 2013 Royal Australasian College of Surgeons
containing the intussuscepted segments, and performed a Rouxand-Y gastrojejunostomy (Fig. 3). No pathologic finding, apart from necrosis, was observed on pathologic examination of the invaginated segment. The patient was discharged on the 8th postoperative day without complication. JGI is a rare complication of partial gastrectomy or gastrojejunostomy (0.15%).1 Early diagnosis and urgent surgical intervention is essential, because a delay in treatment of more than 48 h, following onset of severe symptoms in these cases is associated with a rise of mortality rate from 10% to 50%.2,3 JGI has been described in two clinical forms, acute and chronic. In the acute form, strangulation and incarceration are encountered more frequently. The most notable complaints are severe epigastric pain, vomiting and haematemesis. In the chronic form, spontaneous reductions are seen. Therefore, complaints are not severe and accurate diagnosis is quite difficult.1,4 Gastroscopy may help in diagnosis, however, in the presence of blood, the appearance of the intussuscepted bowel loops may resemble a bleeding gastric tumour.5 In the acute form of the disease and also during the symptomatic period of the chronic form of the disease,3 the contrastenhanced abdominal tomography may show a dilated stomach with intragastric filling by bowel loops.3,6 Three anatomic types of JGI have been described: intussusception of the afferent loop (type 1), efferent loop (type 2) and both loops
Fig. 2. Contrast-enhanced abdominal tomography showing a dilated stomach with intragastric non-homogeneous mass compatible with bowel loops (arrow).
ANZ J Surg 84 (2014) 191–192
192
Images for surgeons
Acknowledgments This study was carried out in Rize University Surgery Department, with the permission of the Department. Dr Pergel is the guarantor for this paper, and takes responsibility for the integrity of the work as a whole.
References
Fig. 3. Intussuscepting bowel segment is delivered out of the gastrotomy incision (black arrow; stomach, white arrow; intussuscepted jejunal segment).
together (type 3). Type 2 is most commonly encountered, accounting for 80% of cases.7 Although the causes of JGI are not clearly defined, factors such as long afferent loop, abnormal motility, hyperacidity, retrograde peristaltism and sudden increase in intra-abdominal pressure have been proposed.5,8 In conclusion, JGI must be considered in the differential diagnoses of patients who have a history of previous gastric surgery along with severe epigastric pain, vomiting, haematemesis or palpable epigastric mass. Particularly in haemorrhagic cases, endoscopic findings may be similar to those for gastric cancer.
1. Waits JO, Beart RW, Charboneau JW. Jejunogastric intussusception. Arch. Surg. 1980; 115: 1449–52. 2. Achyut JM, Ishwar JM, Jayantkumar BD et al. Jejunogastric intussusception: case report and review of the literature. Dig. Endosc. 2004; 16: 88–90. 3. Archimandritis AJ, Hatzopoulos N, Hatzinikolaou P et al. Jejunogastric intussusception presented with hematemesis: a case presentation and review of the literature. BMC Gastroenterol. 2001; 1: 1. 4. Foster DG. Retrograde jejunogastric intussusception; a rare cause of hematemesis. review of the literature and report of two cases. AMA Arch. Surg. 1956; 73: 1009–17. 5. Rather SA, Dar TI, Wani RA, Khan A. Jejunogastric intussusception presenting as tumor bleed. J. Emerg. Trauma Shock 2010; 3: 406–8. 6. Zenooz NA, Holz SP, Robbin MR. Jejunogastric intussusception: a case report with the review of literature. Emerg. Radiol. 2007; 13: 265–7. 7. Reyelt WP, Anderson AA. Retrograde jejunogastric intussusception. Surg. Gynecol. Obstet. 1964; 119: 1305–11. 8. Kim KH, Jang MK, Kim HS et al. Intussusception after gastric surgery. Endoscopy 2005; 37: 1237–43.
Ahmet Pergel,* MD Remzi Adnan Akdogan,† MD Ibrahim Aydin,* MD Ahmet Fikret Yucel,* MD Ibrahim Sehitoglu,‡ MD Dursun Ali Sahin,* MD Departments of *Surgery and †Gastroenterology, School of Medicine, Rize University, and ‡Department of Pathology, Rize Educational and Research Hospital, Rize, Turkey doi: 10.1111/ans.12229
© 2013 Royal Australasian College of Surgeons
