|Year : 2014 | Volume
| Issue : 1 | Page : 47-49
Retrograde jejunogastric intussusception: A case report and review of literature
Ravikumar Gopalakrishnan1, Marimuthu Veerasamy2, Naveen P.G. Ravikumar3
1 Professor and Head of Department, Plastic and Reconstructive Surgery, Thanjavur Medical College, Thanjavur, Tamil Nadu, India
2 Assistant Professor, Department of General Surgery, Thanjavur Medical College, Thanjavur, Tamil Nadu, India
3 Research Fellow, Department, Plastic and Reconstructive Surgery, Thanjavur Medical College, Thanjavur, Tamil Nadu, India
|Date of Web Publication||14-Jul-2014|
No-54-Shanthi Nagar, Thanjavur, Tamilnadu
Source of Support: None, Conflict of Interest: None
Retrograde jejunogastric intussusception ( JGI) is a rare but potentially serious complication of gastrectomy or gastrojejunostomy. Only about 200 cases have been reported in the literature. We present a case of retrograde JGI in a 50-year-old female patient with a history of gastrojejunostomy who had increasing abdominal pain and vomiting for 1 week and hematemesis for 1 day. Emergency endoscopy revealed JGI that was confirmed at laparotomy. The gangrenous efferent limb was resected and a partial gastrectomy with Roux-en-Y-gastrojejunostomy was performed. We present this case for its rarity and the diagnosis of retrograde JGI should be kept in mind when the patients have history of gastric surgery. In our case, the patient was treated as recurrent peptic ulcer and she was referred to us only after she had hematemesis. To avoid mortality, early diagnosis and prompt surgical intervention is mandatory.
Keywords: Gastrojejunostomy, hematemesis, retrograde intussusception
|How to cite this article:|
Gopalakrishnan R, Veerasamy M, Ravikumar NP. Retrograde jejunogastric intussusception: A case report and review of literature. Arch Int Surg 2014;4:47-9
|How to cite this URL:|
Gopalakrishnan R, Veerasamy M, Ravikumar NP. Retrograde jejunogastric intussusception: A case report and review of literature. Arch Int Surg [serial online] 2014 [cited 2022 May 23];4:47-9. Available from: https://www.archintsurg.org/text.asp?2014/4/1/47/136715
| Introduction|| |
Jejunogastric intussusception (JGI) is a rare complication of gastrectomy with an incidence of 0.1%.  It is thought that it can occur any time after several types of gastric operations including gastrojejunostomy and Billroth II resection.  A mortality rate of 10% and even as high as 50% has been reported if surgical intervention has been delayed, therefore, early diagnosis of this condition is mandatory.  Although a history of gastric surgery may help in making such a diagnosis, preoperative awareness of this condition has been reported to be difficult in most of the cases. We report a case of retrograde JGI who presented with abdominal pain, vomiting, and hematemesis. The patient was treated as recurrent peptic ulcer for 1 week and then referred to us when she developed hematemesis. We report this case to stress the importance of early recognition and the role of emergency endoscopy in diagnosing this condition.
| Case Report|| |
We present a 50-year-old female who was admitted with abdominal pain, vomiting, and hematemesis. The patient was treated for recurrent peptic ulcer for 1 week by her physician and was referred to us after she had hematemesis. She had three episodes of hematemesis with frank blood at each time. She had undergone truncal vagotomy and gastrojejunostomy 6 years ago. Physical examination revealed features of shock with pallor and blood pressure of 80/60 mmHg and pulse rate of 110 per min. Abdominal examination revealed a healed supraumbilical midline scar, tender ill-defined lump in the epigastrium.
Plain X-ray of the abdomen did not reveal any significant findings. There was no free gas under the diaphragm. Abdominal ultrasonography done after 1 h of admission showed dilated stomach with presence of small intestinal loops in its lumen. Emergency esophagogastroduodenoscopy done 5 h after admission revealed gastrojejunostomy stoma including both afferent and efferent loops [Figure 1]. Loops of jejunum with mucosal ulceration were found inside the stomach. Duodenal bulb was deformed and second part entered with difficulty.
Emergency exploratory laparotomy was done on the same day after proper resuscitation of the patient. Peroperative findings revealed dilated stomach with retrograde intussusception of 15 cm of the efferent loops of jejunum in the stomach through gastrojejunal stoma [Figure 2]. The efferent intussuscepted loops were found to be gangrenous and were resected [Figure 3]. Partial gastrectomy with Roux-en-Y-gastro jejunostomy was done [Figure 4]. The postoperative period was uneventful and the patient was discharged on 10 th postoperative day.
| Discussion|| |
JGI is a rare complication of gastrojejunostomy, Billroth II gastrectomy, and Roux-en-Y anastomosis.  There are about 200 published cases since its first description in 1914 by Bozzi in a patient with gastrojejunostomy.  In 1922, Lundberg reported a case of JGI in a patient with a history of Billroth II resection.  The incidence of JGI has been estimated to be 3 in 2,000 gastrojejunostomies (0.15%).  The widely accepted anatomical classification proposed by Shackman et al., distinguishes three categories of jejunogastric intussusceptions:  Type I: Afferent loop intussusception (antegrade), type II: Efferent loop intussusception (retrograde), and type III: Combined form.
Efferent loop JGI is seen in 80% of the cases, while others account for the remaining 20%.  Our patient had type II - retrograde intussusception. The exact mechanism of JGI is still not well-understood.  Long afferent loop, jejunal spasm with abnormal motility, increased mobility of the efferent loop, and adhesions leading to the intussusception of a more mobile segment into a fixed segment may be the underlying causes.  It is also postulated that increased intra-abdominal pressure, a dilated atonic stomach especially after vagotomy, and retrograde peristalsis may be responsible for the development of JGI. 
Two different forms of JGI have been described according to its clinical presentation.  In the acute form, there is incarceration and strangulation of the intussuscepted loop causing acute severe epigastric pain, vomiting, and subsequently hematemesis, similar to the presentation in our patient. However, spontaneous reduction is usual in the chronic type. A palpable abdominal mass can be observed in almost half of the cases.  It should be kept in mind that a sudden onset of epigastric pain, vomiting, and subsequent hematemesis, and a palpable epigastric mass in a patient with a previous gastric surgery can be important diagnostic clues for JGI. Therefore, carefully taken history with good physical examination helps to suspect this rare condition in a gastrectomized patient as in this case. Most of the reported cases have not been diagnosed preoperatively. In our case, the condition was suspected and preoperative upper gastrointestinal endoscopy was diagnostic.
The reported mortality rate range from 10% for treatment within the first 48 h to 50% within a 96 h delay.  The surgical options available are manual reduction, resection of gangrenous bowel, and revision of anastomosis. Fixation of the jejunum to adjacent tissue like mesocolon, colon, or stomach may be added to prevent recurrence.
| Conclusion|| |
A high index of suspicion is required for diagnosis of JGI. Early recognition of the acute variant of JGI and prompt surgical intervention is the treatment of choice. Emergency upper gastrointestinal endoscopy plays a vital role in establishing the diagnosis.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]