Reduction
of Jejunogastric
Intussusception Examination
Downloaded from www.ajronline.org by 197.217.85.224 on 11/10/15 from IP address 197.217.85.224. Copyright ARRS. For personal use only; all rights reserved
WILLIAM
In 1948, functional,
Chicago abdominal
with
black
female
the
Report
was admitted
to the University
a hemigastrectomy in the
9 years interim
earlier
and
for the same
four
complaint.
of
periods
the
of
showed
a bulky
nodular
filling
defect,
with
stnia-
During
tion
this
again
remnant,
last
admission,
demonstrated
gastrointestinal
filling
an intussuscepted
bowel
fluid
defect portion
(fig. 1A). In the course
ther-
examina-
of the examina-
a spontaneous reduction of this loop of small bowel was observed (fig. 1B), and a diagnosis of chronic intermittent jejunogastnic intussusception was made. At endoscopy the folds
was widely
patent.
of the stomach
Except
for hypertrophic
and jejunum,
no evidence
the cause occurs
might
be
physio-
causative
and Vestby [7] summarized the authors as follows: since no pathbe found in the intussusceptum,
mechanism
was
believed
to be functional,
Presentation
The two main types of jejunogastnic intussusception are acute and chronic recurrent [6]. Acute delayed jejunogastnic intussusception can occur months or years after gastric surgery. The patients are seen as acute surgical emergencies, and symptoms include nausea and vomiting, colicky abdominal pain, and hematemesis [2, 5, 7, 10-15]. An umbilical mass is often palpable on the left. The cause of this emergency is incarceration of the intussusceptum [16]. Mortality rates rise sharply with delay of surgical decompression of this upper intestinal obstruction: 10% within 48 hr and over 50% in 96 hr [5, 1 3, 1 4] Of seven cases of acute postoperative jejunogastnic intussusception reported by Jackman and Middlemiss [10], only one required additional surgery; the others recovered following treatment by gastric suction and intravenous fluids. Chronic recurrent jejunogastnic intussusception is frequently characterized by recurrent abdominal pain relieved by intermittent vomiting. The diagnosis is made by upper gastrointestinal tract examination, and the treatment usually consists of gastric suction and intravenous fluids [10, 17]. When incarceration of the chronic recurrent type of jejunogastnic intussusception occurs, it presents clinically as the acute type.
in the gastric of the efferent
tion,
stoma
that penistalsis
gut.
Clinical
upper
a nodular
representing
loop of the small
and intravenous
retrograde
.
tions typical of jejunogastric intussusception, within the gastric remnant. In previous hospitalizations the acute symptoms had
subsided after nasogastnic suction apy, and no diagnosis was made.
[5] suggested
since
probably related to spasm and penistalsis. Hyperpenistalsis in the small bowel after gastric surgery [8], in addition to excessive mobility of the jejunum [9], could promote i ntussusception Antecolic anastomosis also contributes to this excessive mobility and thereby favors intussusception.
Although
a diagnosis of jejunogastnic intussusception was made on the last admission only, a review of previous upper gastrointestinal examinations
Aleman
In 1957, Hertzberg conclusions of earlier ologic change could
Hospitals and Clinics with the complaint of intermittent pain for 1 month. She had had a Billroth II operation
hospitalization
Gastrointestinal
logically in the small bowel. However, he noted that retrograde penistalsis can also be induced by an unusual element in the diet. Penman (cited in [5]) observed that widening of the upper jejunum occurs gradually following gastroenterostomy, which tends to produce jejunogastric intussusception as a late complication. Burdman [6] stated that an unusually severe contraction of the intestine could initiate jejunogastnic intussusception, and the contracted segment could then prolapse in a retrograde manner into the relaxed proximal segment of
tion.
A 49-year-old
Upper
J. MARX’
Jejunogastric intussusception is an ever-present risk and a potentially lethal complication of gastric surgery. The incidence of jejunogastnic intussusception has been estimated to be three in 2,000 gastroenterostomies (.0015%) [1]. It has been a reported complication of virtually every type of gastroenterostomy from 5 days to 35 years after surgery [2]. Since it was first described by Bozzi in 1914 [3], over 150 cases have been reported. However, few reports have appeared in the radiologic literature, and none have shown reduction of the intussusception during an upper gastrointestinal examinaCase
during
erythematous of intussuscep-
tion was seen. Discussion Etiology
.
There are many theories on the etiology of jejunogastnic intussusception, but no cause common to all cases has been found. In a review of the 96 cases in the literature up to 1966 [2], 54% had Polya anastomoses, and 38% had Billroth II gastroenterostomies. Both procedunes produce widely patent gastroentenic anastomoses, which may favor jejunogastnic intussusception. Shiffman and Rappaport [2] emphasized that loose mucosa at the anatomotic site may prolapse into the gastric pouch
less bulk
during
normal
common afferent of the jejunogastnic
penistalsis.
This
loop intussusception, intussusceptions
could
explain
the
but not the [4] (fig. 2).
Received December 20, 1977; accepted after revision March 30, 1978. Department of Radiology. University of Chicago, 950 East 59th Street. American Hospital, Rockford School of Medicine, Rockford, Illinois 61101 ‘
Am J Roentgenol © 1978 American
131 :334-336, August Roentgen Ray Society
1978
Chicago. .
Address
334
Illinois
60637.
reprint
requests
Present
address:
to Chicago
Department
of Radiology,
Swedish-
address.
0361 -803X/78/08-0334
$00.00
Downloaded from www.ajronline.org by 197.217.85.224 on 11/10/15 from IP address 197.217.85.224. Copyright ARRS. For personal use only; all rights reserved
CASE
335
REPORTS
.,
.
tA Fig.
1.-Upper
intussuscepted
-
__
gastrointestinal
efferent
A\
examination.
loop. B, 6 mm later there
A, Bulky nodular filling is spontaneous reduction
susceptum,
B\
))nh)
defect within of jejunogastric
may
nosis
be present
[15].
does
is
It
tially
It also
recurrent lethal
A, Normal , Type 2afferent
and
tinal
The cardinal radiographic feature of jejunogastnic intussusception is the demonstration of a helical filling defect within the gastric pouch during an upper gastrointestinal examination [2, 7, 13]. This represents the presence of contrast material between the valvulae conniventes and surrounding the intussusceptum. Our case demonstrated a nodular bulky appearance of the intus-
can
be
of the
a negative
as
an
[2, 10, of this
gastroscopy
because
of the reduced
examination,
by the hyptonia
that
the upper gastrointestinal attempt to differentiate intussusception
the
ered the chronic intussusceptions cause
Radiography
recognized
intussusception are suggestive
intussusception is intermitdoes not disprove the diag-
follows
complications
susceptum Fig. 2.-Types of jejunogastnic intussusceptions. B, Type 1 -afferent loop intussusception. efferent loop intussusception. D, Type 3-combined efferent loop intussusception.
be
represents
[13].
recurrent laparotomy
not contradict important to
chronic
anatomy.
also
sign of jejunogastnic radiographic findings
Since chronic tent, a negative
D\=1
should
pouch
condition: in the case of a gastroenterostomy without gastric resection, barium reentering the stomach from the efferent loop, displacement of the pylorus and duodenal bulb to the right, or dilatation of the duodenal loop may be seen; in the case of a gastroenterostomy with or without a gastric resection, gastric dilatation and netention
Cv
which
important 16]. Other
hJ2
barium-filled gastric intussusception.
during
upper
poten-
If the
intus-
gastrointes-
can
type. reduced
direction
of the
type.
intussusception
recurrent may be
favorable
acute
findings. acute from
be
consid-
Some jejunogastnic at fluonoscopy be-
of the
barium [15]. In other cases, may promote reduction.
pressure
exerted
glucagon-induced
REFERENCES 1
.
Conklin EF, Markowitz AM: Intussusception, a complication of gastric surgery. Surgery 57:480-488, 1965
2. Shiffman
MA, Rappaport
I: Intussusception
tnic resection: report of five cases Surg 32:715-724, 1966 3.
Bozzi
E:
So
di
una
rara
complicanza
following
and literature consecutiva
gas-
review. a
Am
gas-
336
CASE troenterostomia 4:122, 1914
4.
Shackman
Downloaded from www.ajronline.org by 197.217.85.224 on 11/10/15 from IP address 197.217.85.224. Copyright ARRS. For personal use only; all rights reserved
6.
7. 8.
9.
10.
Aleman
v. Hacker.
Boll
Acad
Med
susception.
Genova
BrJSurg R:
27:475-480, 5.
alla
REPORTS
Jejunogastnic
intussusception.
Br
J Surg
11.
susception after Surg 38:172-175,
1940
5: Jejuno-gastnic intussusception. A rare compliof the operated stomach. Acta Radiol 29:383-395,
cation 1948 Burdman M: Report of a case of thrice occurring retrograde intussusception of the efferent loop of jejunum through a gastroenterostomy stoma with a theory as to aetiology. Postgrad Med J 30 : 200-204, 1954 Hertzberg J, Vestby GW: Retrograde jejunogastric intussusception. J Oslo City Hosp 7 : 193-200, 1957 Liljedahl SO, Mattson 0, Pernow B, Wallensten 5: Cineroentgenographic studies on gastrointestinal mobility in healthy subjects and in patients with gastric or duodenal ulcer. Acta Chir Scand 11 7 : 206-214, 1959 Salem MH, Coffman SE, Postlewaite RW: Retrograde intussusception at the gastrojejunal stoma. Ann Surg 150:864871, 1959 Jackman M Middlemiss JH : Retrograde jejunogastric intus,
Walstad
A review of 10 cases diagnosed radiologically. 49:260-265, 1961 PM, Ritter JA, Arroz V: Delayed jejunogastnic intus-
12. Wisoff
CP:
61 :363-367,
gastric
surgery:
1972 Jejunogastric
an ever-present
intussusception.
threat.
Am
Radiology
1953
13. Devon D, Passaro E Jr: Jejunogastnic intussusception: review of four cases-diagnosis and management. Ann Surg 163:93-96, 1966 14. Hovelius L: Jejunogastnic intussusception after gastric resection. A report of two cases. Acta Chir Scand 137:491494, 1971 15.
Mulero
HL,
Carvalno
HP,
Knechtges
TC:
Jejunogastnic
intussusception: an infrequently recognized cause of postgastrectomy complications. Am J Dig Dis 1 2 : 639-645, 1967 16.
Osmond
17.
with a report of a case. Am J Roentgenol 79 : 786-788, 1958 Palmer ED: Retrograde intussusception at the gastrojejunal stoma: two cases and bibliography. Am J Dig Dis 21 :309-
313, 1954
JO,
Fowler
HO: Jejunogastnic
intussusception:
of Jejunogastric
Intussusception Examination
Downloaded from www.ajronline.org by 197.217.85.224 on 11/10/15 from IP address 197.217.85.224. Copyright ARRS. For personal use only; all rights reserved
WILLIAM
In 1948, functional,
Chicago abdominal
with
black
female
the
Report
was admitted
to the University
a hemigastrectomy in the
9 years interim
earlier
and
for the same
four
complaint.
of
periods
the
of
showed
a bulky
nodular
filling
defect,
with
stnia-
During
tion
this
again
remnant,
last
admission,
demonstrated
gastrointestinal
filling
an intussuscepted
bowel
fluid
defect portion
(fig. 1A). In the course
ther-
examina-
of the examina-
a spontaneous reduction of this loop of small bowel was observed (fig. 1B), and a diagnosis of chronic intermittent jejunogastnic intussusception was made. At endoscopy the folds
was widely
patent.
of the stomach
Except
for hypertrophic
and jejunum,
no evidence
the cause occurs
might
be
physio-
causative
and Vestby [7] summarized the authors as follows: since no pathbe found in the intussusceptum,
mechanism
was
believed
to be functional,
Presentation
The two main types of jejunogastnic intussusception are acute and chronic recurrent [6]. Acute delayed jejunogastnic intussusception can occur months or years after gastric surgery. The patients are seen as acute surgical emergencies, and symptoms include nausea and vomiting, colicky abdominal pain, and hematemesis [2, 5, 7, 10-15]. An umbilical mass is often palpable on the left. The cause of this emergency is incarceration of the intussusceptum [16]. Mortality rates rise sharply with delay of surgical decompression of this upper intestinal obstruction: 10% within 48 hr and over 50% in 96 hr [5, 1 3, 1 4] Of seven cases of acute postoperative jejunogastnic intussusception reported by Jackman and Middlemiss [10], only one required additional surgery; the others recovered following treatment by gastric suction and intravenous fluids. Chronic recurrent jejunogastnic intussusception is frequently characterized by recurrent abdominal pain relieved by intermittent vomiting. The diagnosis is made by upper gastrointestinal tract examination, and the treatment usually consists of gastric suction and intravenous fluids [10, 17]. When incarceration of the chronic recurrent type of jejunogastnic intussusception occurs, it presents clinically as the acute type.
in the gastric of the efferent
tion,
stoma
that penistalsis
gut.
Clinical
upper
a nodular
representing
loop of the small
and intravenous
retrograde
.
tions typical of jejunogastric intussusception, within the gastric remnant. In previous hospitalizations the acute symptoms had
subsided after nasogastnic suction apy, and no diagnosis was made.
[5] suggested
since
probably related to spasm and penistalsis. Hyperpenistalsis in the small bowel after gastric surgery [8], in addition to excessive mobility of the jejunum [9], could promote i ntussusception Antecolic anastomosis also contributes to this excessive mobility and thereby favors intussusception.
Although
a diagnosis of jejunogastnic intussusception was made on the last admission only, a review of previous upper gastrointestinal examinations
Aleman
In 1957, Hertzberg conclusions of earlier ologic change could
Hospitals and Clinics with the complaint of intermittent pain for 1 month. She had had a Billroth II operation
hospitalization
Gastrointestinal
logically in the small bowel. However, he noted that retrograde penistalsis can also be induced by an unusual element in the diet. Penman (cited in [5]) observed that widening of the upper jejunum occurs gradually following gastroenterostomy, which tends to produce jejunogastric intussusception as a late complication. Burdman [6] stated that an unusually severe contraction of the intestine could initiate jejunogastnic intussusception, and the contracted segment could then prolapse in a retrograde manner into the relaxed proximal segment of
tion.
A 49-year-old
Upper
J. MARX’
Jejunogastric intussusception is an ever-present risk and a potentially lethal complication of gastric surgery. The incidence of jejunogastnic intussusception has been estimated to be three in 2,000 gastroenterostomies (.0015%) [1]. It has been a reported complication of virtually every type of gastroenterostomy from 5 days to 35 years after surgery [2]. Since it was first described by Bozzi in 1914 [3], over 150 cases have been reported. However, few reports have appeared in the radiologic literature, and none have shown reduction of the intussusception during an upper gastrointestinal examinaCase
during
erythematous of intussuscep-
tion was seen. Discussion Etiology
.
There are many theories on the etiology of jejunogastnic intussusception, but no cause common to all cases has been found. In a review of the 96 cases in the literature up to 1966 [2], 54% had Polya anastomoses, and 38% had Billroth II gastroenterostomies. Both procedunes produce widely patent gastroentenic anastomoses, which may favor jejunogastnic intussusception. Shiffman and Rappaport [2] emphasized that loose mucosa at the anatomotic site may prolapse into the gastric pouch
less bulk
during
normal
common afferent of the jejunogastnic
penistalsis.
This
loop intussusception, intussusceptions
could
explain
the
but not the [4] (fig. 2).
Received December 20, 1977; accepted after revision March 30, 1978. Department of Radiology. University of Chicago, 950 East 59th Street. American Hospital, Rockford School of Medicine, Rockford, Illinois 61101 ‘
Am J Roentgenol © 1978 American
131 :334-336, August Roentgen Ray Society
1978
Chicago. .
Address
334
Illinois
60637.
reprint
requests
Present
address:
to Chicago
Department
of Radiology,
Swedish-
address.
0361 -803X/78/08-0334
$00.00
Downloaded from www.ajronline.org by 197.217.85.224 on 11/10/15 from IP address 197.217.85.224. Copyright ARRS. For personal use only; all rights reserved
CASE
335
REPORTS
.,
.
tA Fig.
1.-Upper
intussuscepted
-
__
gastrointestinal
efferent
A\
examination.
loop. B, 6 mm later there
A, Bulky nodular filling is spontaneous reduction
susceptum,
B\
))nh)
defect within of jejunogastric
may
nosis
be present
[15].
does
is
It
tially
It also
recurrent lethal
A, Normal , Type 2afferent
and
tinal
The cardinal radiographic feature of jejunogastnic intussusception is the demonstration of a helical filling defect within the gastric pouch during an upper gastrointestinal examination [2, 7, 13]. This represents the presence of contrast material between the valvulae conniventes and surrounding the intussusceptum. Our case demonstrated a nodular bulky appearance of the intus-
can
be
of the
a negative
as
an
[2, 10, of this
gastroscopy
because
of the reduced
examination,
by the hyptonia
that
the upper gastrointestinal attempt to differentiate intussusception
the
ered the chronic intussusceptions cause
Radiography
recognized
intussusception are suggestive
intussusception is intermitdoes not disprove the diag-
follows
complications
susceptum Fig. 2.-Types of jejunogastnic intussusceptions. B, Type 1 -afferent loop intussusception. efferent loop intussusception. D, Type 3-combined efferent loop intussusception.
be
represents
[13].
recurrent laparotomy
not contradict important to
chronic
anatomy.
also
sign of jejunogastnic radiographic findings
Since chronic tent, a negative
D\=1
should
pouch
condition: in the case of a gastroenterostomy without gastric resection, barium reentering the stomach from the efferent loop, displacement of the pylorus and duodenal bulb to the right, or dilatation of the duodenal loop may be seen; in the case of a gastroenterostomy with or without a gastric resection, gastric dilatation and netention
Cv
which
important 16]. Other
hJ2
barium-filled gastric intussusception.
during
upper
poten-
If the
intus-
gastrointes-
can
type. reduced
direction
of the
type.
intussusception
recurrent may be
favorable
acute
findings. acute from
be
consid-
Some jejunogastnic at fluonoscopy be-
of the
barium [15]. In other cases, may promote reduction.
pressure
exerted
glucagon-induced
REFERENCES 1
.
Conklin EF, Markowitz AM: Intussusception, a complication of gastric surgery. Surgery 57:480-488, 1965
2. Shiffman
MA, Rappaport
I: Intussusception
tnic resection: report of five cases Surg 32:715-724, 1966 3.
Bozzi
E:
So
di
una
rara
complicanza
following
and literature consecutiva
gas-
review. a
Am
gas-
336
CASE troenterostomia 4:122, 1914
4.
Shackman
Downloaded from www.ajronline.org by 197.217.85.224 on 11/10/15 from IP address 197.217.85.224. Copyright ARRS. For personal use only; all rights reserved
6.
7. 8.
9.
10.
Aleman
v. Hacker.
Boll
Acad
Med
susception.
Genova
BrJSurg R:
27:475-480, 5.
alla
REPORTS
Jejunogastnic
intussusception.
Br
J Surg
11.
susception after Surg 38:172-175,
1940
5: Jejuno-gastnic intussusception. A rare compliof the operated stomach. Acta Radiol 29:383-395,
cation 1948 Burdman M: Report of a case of thrice occurring retrograde intussusception of the efferent loop of jejunum through a gastroenterostomy stoma with a theory as to aetiology. Postgrad Med J 30 : 200-204, 1954 Hertzberg J, Vestby GW: Retrograde jejunogastric intussusception. J Oslo City Hosp 7 : 193-200, 1957 Liljedahl SO, Mattson 0, Pernow B, Wallensten 5: Cineroentgenographic studies on gastrointestinal mobility in healthy subjects and in patients with gastric or duodenal ulcer. Acta Chir Scand 11 7 : 206-214, 1959 Salem MH, Coffman SE, Postlewaite RW: Retrograde intussusception at the gastrojejunal stoma. Ann Surg 150:864871, 1959 Jackman M Middlemiss JH : Retrograde jejunogastric intus,
Walstad
A review of 10 cases diagnosed radiologically. 49:260-265, 1961 PM, Ritter JA, Arroz V: Delayed jejunogastnic intus-
12. Wisoff
CP:
61 :363-367,
gastric
surgery:
1972 Jejunogastric
an ever-present
intussusception.
threat.
Am
Radiology
1953
13. Devon D, Passaro E Jr: Jejunogastnic intussusception: review of four cases-diagnosis and management. Ann Surg 163:93-96, 1966 14. Hovelius L: Jejunogastnic intussusception after gastric resection. A report of two cases. Acta Chir Scand 137:491494, 1971 15.
Mulero
HL,
Carvalno
HP,
Knechtges
TC:
Jejunogastnic
intussusception: an infrequently recognized cause of postgastrectomy complications. Am J Dig Dis 1 2 : 639-645, 1967 16.
Osmond
17.
with a report of a case. Am J Roentgenol 79 : 786-788, 1958 Palmer ED: Retrograde intussusception at the gastrojejunal stoma: two cases and bibliography. Am J Dig Dis 21 :309-
313, 1954
JO,
Fowler
HO: Jejunogastnic
intussusception:
