Journal of Dr. NTR University of Health Sciences

CASE REPORT
Year
: 2013  |  Volume : 2  |  Issue : 3  |  Page : 212--214

Retrograde jejunogastric intussusception: A rare case report and review of literature


Narasimhaiah Lingaraju, Sushrut Madhukar Fulare, Reddyppa David Sadhu, Sapthagiri Prasad Ramayanam 
 Department of General Surgery, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India

Correspondence Address:
Narasimhaiah Lingaraju
No. 214, PG Hostel, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh
India

Abstract

Retrograde jejunogastric intussusception (JGI) is an unusual complication following gastrojejunostomy and Billroth II gastrectomy. It was first described in 1914 by Bozzi in a patient with gastrojejunostomy, and about 300 cases have been reported so far in the medical literature. High index clinical suspicion is required to make the diagnosis. Pyloroplasty is one of the well-accepted and proven surgical options in such cases. We report a case of retrograde JGI involving both loops of jejunum in a male patient who underwent truncal vagotomy and posterior gastrojejunostomy for chronic duodenal ulcer 6 years ago.



How to cite this article:
Lingaraju N, Fulare SM, Sadhu RD, Ramayanam SP. Retrograde jejunogastric intussusception: A rare case report and review of literature.J NTR Univ Health Sci 2013;2:212-214


How to cite this URL:
Lingaraju N, Fulare SM, Sadhu RD, Ramayanam SP. Retrograde jejunogastric intussusception: A rare case report and review of literature. J NTR Univ Health Sci [serial online] 2013 [cited 2020 Aug 10 ];2:212-214
Available from: http://www.jdrntruhs.org/text.asp?2013/2/3/212/117198


Full Text

 Introduction



Jejunogastric intussusception (JGI) is a rare complication following posterior gastrojejunostomy, Billroth II partial gastrectomy, and Roux-en-Y gastrojejunostomy. [1] Its estimated frequency is approximately 0.1% and close to 300 cases has been recorded in the medical literature. [2] However, 87.7% of intussusceptions following abdominal surgery occur after gastrectomy. [3] Two forms of JGI have been clinically recognized: An acute and a chronic form. We report a case of retrograde JGI involving both loops of jejunum which was managed successfully with a less morbid procedure, that is, pyloroplasty as against conventional Roux-en-Y anastomosis.

 Case Report



A 50-year-old male patient presented to emergency room with complaints of acute abdominal pain and vomiting for 2 days. He underwent truncal vagotomy and gastrojejunostomy for chronic duodenal ulcer 6 years ago. On clinical examination; patient was dehydrated, pulse was 108/min, and blood pressure was 100/60 mmHg. Abdominal examination revealed upper midline abdominal scar which healed by primary intention. Ultrasonography abdomen and pelvis revealed retrograde JGI through previous gastrojejunostomy with edematous walls of intussusceptions, along with 1 cm gall stone in fundus of gallbladder [Figure 1]. Upper gastrointestinal endoscopy showed intussusception of small bowel at gastrojejunal anastomosis [Figure 2].{Figure 1}{Figure 2}

At laparotomy, stomach was dilated and both efferent and afferent loops were intussuscepted in a retrograde fashion into gastric lumen [Figure 3]. Reduction of JGI with resection of gangrenous jejunum [Figure 4] and end-to-end anastomosis was performed along with closure of gastric stoma. As the duodenum appeared normal and vagotomy was complete, Heineke-Mikulicz pyloroplasty was performed. Cholecystectomy was performed for 1 cm stone in the fundus of gallbladder. Postoperative recovery was uneventful and patient was discharged on the tenth postoperative day.{Figure 3}{Figure 4}

 Discussion



JGI was first described in 1914 by Bozzi in a patient with gastrojejunostomy. The widely accepted anatomical classification proposed by Shackman et al., distinguishes three categories of jejuno gastric intussusception; Type I: Afferent loop intussusception (antegrade), Type II: Efferent loop intussusception (retrograde), Type III: Combined form. [4] There is a wide variation in the lapse time between gastric operation and JGI to occur: 6 days to 20 years and 8 days to 19 years in patients with gastrojejunostomy and partial gastrectomy, respectively. [5] The cause (s) of JGI is poorly understood. Various factors such as hyperacidity, long afferent loop, jejunal spasm with abnormal motility, increased intra-abdominal pressure, retrograde peristalsis, etc., have been incriminated. [6] Probably, retrograde peristalsis, which can occur in normal people prior to gastric surgery, seems to be accepted as the cause of type II JGI. Two forms of JGI have been clinically recognized: An acute and a chronic form. In the acute form, incarceration and strangulation of the intussuscepted loop generally occurs whilst spontaneous reduction is usual in the chronic type. Thus, the acute form is characterized by acute severe colicky epigastric pain, vomiting, and hematemesis. Epigastric tenderness and palpable abdominal mass can be observed in about 50% and signs of high intestinal obstruction can also be found. [6],[7] It should be pointed out that a sudden onset of epigastric pain, vomiting, hematemesis, and palpable epigastric mass in a patient with a previous gastric surgery are thought as the classic triad of JGI. [7] The reported mortality rate ranges from 10% for treatment within the first 48 h to 50% with a 96-h delay. [8] Endoscopy performed by someone familiar with this rare entity, is certainly diagnostic. In the chronic form, the diagnosis is difficult. The main reason for this is that upper gastrointestinal series or upper gastrointestinal endoscopy must be performed during symptomatic period for diagnosis to be confirmed. However, it has been suggested that in the asymptomatic period, provocation of JGI during endoscopy by use of a jet of water directed towards anastomotic stoma may be diagnostic of chronic form. [9] Surgical options include reduction, resection, and revision of anastomosis and take-down of anastomosis; depending on the conditions found during operation.

Pyloroplasty can be considered as one of the treatment options as it offers many advantages: a) Does not alter the continuity of gastrointestinal tract; b) decreases the possibility of marginal ulceration, stump carcinoma occasionally seen after gastrojejunostomy; c) avoids another anastomosis; d) carries a low surgical morbidity and mortality rate because of its technical simplicity. [10]

 Conclusion



A high index of suspicion is required for diagnosis of JGI. Early recognition of acute variant of JGI and prompt surgical intervention is the treatment of choice. Pyloroplasty can be considered as one of the viable surgical options as it offers a low morbidity and mortality in such patients. Patient was well and no symptoms were observed at 6 weeks follow-up.

References

1Wheatley MJ. Jejunogastric intussusception diagnosis and management. J Clin Gastroenterol 1989;11:452-4.
2Herbella FA, Del Grande JC. Radiology for the surgeon. Soft-tissue case 53. Postgastrectomy jejunogastric intussusception. Can J Surg 2003;46:465-6.
3Narita H, Funabashi K, Yoshitomi H, Yamamori N, Iguchi T, Hori K, et al. Post operative intussusceptions-report of a case, and a comparison between adult and pediatric intussusceptions after laparotomy 1991;52:2125-31.
4Shackman R. Jejunogastric intussusception. Br J Surg 1940;27:475-80.
5Reyelt WP Jr, Anderson AA. Retrograde Jejunogastric Intussusception. Surg Gynecol Obstet 1964;119:1305-11.
6Conklin EF, Markowitz AM. Intussusception, a complication of gastric surgery. Surgery 1965;57:480-8.
7White TT, Harrison RC. Reoperative Gastrointestinal Surgery. New York City: Little Brown and Company; 1973.
8Walstad PM, Ritter JA, Arroz V. Delayed jejunogastric intussusception after gastric surgery: An ever present threat. Am Surg 1972;38:172-5.
9Truong SN, Tittel A, Schumpelick V. Jejunogastric invagination--a rare complication of stomach surgery. Z Gastroenterol 1992;30:798-800.
10Williams JA, Fielding JF. Recurrent acute retrograde intragastric intussusceptions. Gut 1970;11:840-2.