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LETTER TO THE EDITOR
Year : 2014  |  Volume : 3  |  Issue : 2  |  Page : 140-142

Retrograde jejunogastric intussusception: Review of two cases


Department of General Surgery, Kurnool Medical College, Government General Hospital, Kurnool, Andhra Pradesh, India

Date of Web Publication20-Jun-2014

Correspondence Address:
Haricharan Perigela
Department of General Surgery, Kurnool Medical College, Government General Hospital, Kurnool, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.134894

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How to cite this article:
Perigela H, Maramreddy K, Bangi V, Nagabhushigari S. Retrograde jejunogastric intussusception: Review of two cases. J NTR Univ Health Sci 2014;3:140-2

How to cite this URL:
Perigela H, Maramreddy K, Bangi V, Nagabhushigari S. Retrograde jejunogastric intussusception: Review of two cases. J NTR Univ Health Sci [serial online] 2014 [cited 2019 Aug 19];3:140-2. Available from: http://www.jdrntruhs.org/text.asp?2014/3/2/140/134894

Sir,

Retrograde jejunogastric intussusception (RJI) occurs in acute or chronic form, the acute form being fatal without timely surgical intervention. Early diagnosis of this condition and prompt surgical intervention is mandatory. Here we report two cases who were admitted to the hospital with the diagnosis of upper gastrointestinal (GI) bleeding. RJI was diagnosed by upper GI endoscopy and computed tomography (CT) scan abdomen in one case and by ultrasound abdomen in the other.

First patient, a 45-year-old male, presented with a history of upper abdominal pain since 2 days and 3 episodes of hematemesis. He had undergone truncal vagotomy and gastro-jejunostomy 20 years ago for chronic duodenal ulcer. On examination, his vital data was normal. Abdominal examination revealed a healed supraumbilical midline incisional scar. Epigastric tenderness was present, but there was no palpable mass. Chest X-ray and plain X-ray abdomen in erect position were normal. Abdominal ultrasonography revealed a multilayered bowel mass in the stomach with possibility of RJI. Emergency endoscopy disclosed a bulky, lobulated, congestive mass with petechial bleeding, protruding through the stoma into the gastric lumen, that occupied practically the anterior wall of the stomach and part of the greater curvature. The mass was sharply demarcated and the adjacent gastric mucosa was normal. Contrast enhanced CT scan of the abdomen showed jejunal loops within the stomach [Figure 1] and [Figure 2]. The diagnosis of jejunogastric intussusception (JGI) was established and a laparotomy was performed.
Figure 1: Computed tomography scan of abdomen showing retrograde jejunogastric intussusception

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Figure 2: Computed tomography scan of abdomen in coronal view showing jejunal loops in the stomach

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At laparotomy, the efferent loop was found intussuscepted in a retrograde way into the gastric lumen [Figure 3]. After gastrostomy, reduction of the JGI was performed without resection of the intussuscepted intestine, which was edematous with serosal petechiae, but absolutely viable [Figure 4] and [Figure 5]. The efferent loop was fixed to the transverse mesocolon. Gastrostomy wound was closed in two layers. Postoperative recovery was uneventful and the patient was discharged on 10 th postoperative day.
Figure 3: Efferent jejunal loops protruding through the gastrojejunostomy stoma

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Figure 4: Efferent jejunal loops in the stomach

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Figure 5: Pregangrenous jejunal loop after reduction of intussusception

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Second patient, a 65-year-old male, presented with severe abdominal pain and hematemesis. The patient had undergone gastro-jejunostomy and truncal vagotomy 35 years ago for chronic duodenal ulcer. On examination, his pulse rate was 120/min and blood pressure was 100/70 mm Hg. Abdominal examination revealed supraumbilical scar with mass in the epigastrium. Plain X-ray abdomen in erect posture was normal. Emergency ultrasound examination revealed loops of jejunum in the stomach suggestive of RJI. As we had the experience with the first one, after resuscitation, laparotomy was planned.

At laparotomy, the efferent loop of jejunum was found intussuscepted into the gastric lumen. Gastrostomy was not done here. The loops of the jejunum were gently pulled from outside directly by manipulation [Video 1]. The bowel loop was viable and it was fixed to transverse mesocolon. Patient was shifted to surgical intensive care unit and was connected to ventilator. He expired later, 6 h after the procedure.

In our review, both the cases were of Type II, where only efferent loop was intussuscepted. Retrograde peristalsis, which can occur in normal people prior to gastric surgery, seems to be accepted as the cause of Type II JGI. [1] If the patient is stable, CT scan abdomen and upper GI endoscopy can be done as in the first case. Experienced radiologists can diagnose this condition by ultrasound.

Retrograde jejunogastric intussusception is a well-recognized, rare, long-term complication of gastro-jejunostomy or Billroth-II reconstruction. [2] The dominant symptom is pain, occasionally associated with nausea and vomiting. Patients may present with high intestinal obstruction or severe hematemesis from secondary ulceration. [3] A firm mass may be palpable in the epigastrium. A water-soluble upper GI contrast study may reveal a "coiled-spring" appearance within the stomach. Upper GI endoscopic examination is often diagnostic and may visualize the jejunal segments as they migrate in and out of the stomach. When a patient presents with hematemesis and has a mobile upper abdominal mass with visible peristalsis, and bears an upper midline or paramedian scar, one should suspect this complication first. [2],[3] There are two clinical types in an acute variety. [3] In the Type I, the patient is suddenly seized with an acute attack of epigastric pain followed by a sensation of severe constriction of abdomen. There will be visible peristalsis and a mass may be palpable in the epigastrium. Here, early operation has proved to be lifesaving in 90% of the cases. The second variety may closely resemble a bleeding anastomotic ulcer, the dumping syndrome or proximal loop syndrome or obstruction due to adhesions. Vomiting is frequent, being at first bloodstained and then frankly hemorrhagic. Since the medical line of treatment is usually tried first, a delay in surgery occurs causing more morbidity and mortality. However, spontaneous reduction is rare.

The chronic variety is characterized by recurrent bouts of epigastric distress, nausea, and colicky abdominal pain. Intermittent and sometimes severe vomiting occurs at a remote date after gastro-jejunostomy barium meal study is useful and gastroscopy is a valuable diagnostic tool. [3],[4]

The main purpose of this presentation is that we can successfully reduce the bowel loops without gastrostomy as in the second case.

 
  References Top

1.Waits JO, Beart RW Jr, Charboneau JW. Jejunogastric intussusception. Arch Surg 1980;115:1449-52.  Back to cited text no. 1
[PUBMED]    
2.Soybel DI, Zinner MJ. Complications following gastric operation. In: Zinner MJ, editor. Maingot's Abdominal Operations. 10 th ed. USA: Appleton & Lange; 1997. p. 1046.  Back to cited text no. 2
    
3.Menezes LT, D'Cruz A. Retrograde jejunogastric intussusception following gastric surgery. J Indian Med Assoc 1986;84:310-1.  Back to cited text no. 3
    
4.Archimandritis AJ, Hatzopoulos N, Hatzinikolaou P, Sougioultzis S, Kourtesas D, Papastratis G, et al. Jejunogastric intussusception presented with hematemesis: A case presentation and review of the literature. BMC Gastroenterol 2001;1:1.  Back to cited text no. 4
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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