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|Year : 1986 | Volume
| Issue : 2 | Page : 105-6
Retrograde jejunogastric intussusception : an unusual cause of hematemesis (a case report).
Gupta SS, Singh GG
|How to cite this article:|
Gupta S S, Singh G G. Retrograde jejunogastric intussusception : an unusual cause of hematemesis (a case report). J Postgrad Med 1986;32:105
Jejunogastric intussusception is a serious though uncommon complication of gastroenteric anastomosis. The first case of this complication was described by Bozzi in 1914. Less than 200, cases have been reported in the literature. The following is the report of retrograde intragastric intussusception of the efferent loop developed in a patient who had gastrojejunostomy performed 7 years earlier.
A 35 year old male patient was admitted to the emergency ward of the University Hospital on December 2, 1982 with pain in the abdomen, vomiting and hematemesis of 4 days' duration. Seven years earlier, he had undergone truncal vagotomy and posterior retrocolic gastrojejunostomy for the treatment of chronic duodenal ulcer. He had been asymptomatic until his recent admission to the emergency ward. On examination, the patient was found dehydrated. Pulse rate was 126/minute and blood pressure 100/66 mm of mercury. There was epigastric tenderness but no palpable mass. Laboratory investigations showed hemoglobin 9.0 gm%, white cell count 21,000/cmm with 79% polymorphs, 20% lymphocytes, and 1 % eosinophils; blood sugar 140 mg% and normal urinalysis. Plain X-ray of the abdomen was within normal limits.
Initial treatment was resuscitative by intravenous fluids. blood transfusions and nasogastric suction. In view of continued bleeding and high amount of gastric aspirate, a diagnosis of bleeding recurrent ulcer was made and an emergency laparotomy was performed as soon as his general condition was stabilised. At laparotomy, a distended stomach filled with a soft mass was encountered. The presence of posterior gastrojejunostomy was confirmed. The efferent jejunal loop was invaginating through the gastrojejunal stoma into the stomach.
By gentle traction and compression of the intussusceptum, two feet of efferent loop of the jejunum was reduced. The reduced segment of jejunum was edematous, congested and hemorrhagic but did not require resection. The efferent loop of the gatrojejunostomy was anchored to the transverse mesocolon by nonabsorbable sutures to prevent recurrence of the intussusception. The post-operative recovery was uneventful and he was discharged on the 9th postoperative day. He has remained asymptomatic since then.
The jejunogastric intussusception has been reported after every type of gastroenteric anastomosis except Billroth I. Patients with jejunogastric intussusception may be divided into two categories: acutefulminant or chronic-intermittent. The acute forms are distinguishable by the five classic manifestations: severe colicky epigastric pain, vomiting, hematemesis, a palpable abdominal mass, and clinical high intestinal obstruction. Our patient belonged to the acute variety. However, a palpable mass which is found in only about one third of the cases was not present in our case. In the chronic type of jejunogastric intussusception, the patient experiences recurrent episodes of vague upper abdominal discomfort, which is often interpreted as a typical dumping syndrome, marginal ulcer or neurosis. The chronic recurrent variety is more common.3 The widely accepted anatomical classification proposed by Shackman distinguishes three categories of jejunogastric intussusception: type 1, afferent limb intussusception (antegrade); type 2, efferent limb intussusception (retrograde); type 3, combined. Our patient had jejunogastric intussusception of type 2.
This complication may occur at a variable period after original gastric operation. The shortest interval reported is two days and the longest 30 years with an average of 6 years. Most reported cases have not been diagnosed pre-operatively.,  The main pitfall in diagnosis is a low index of suspicion. The presence of pain, vomiting, hematemesis and a mobile mass in a patient who has had previous gastric surgery is considered virtually pathognomonic of acute intussusception. However, the diagnosis can be confirmed by barium meal and gastroscopy. The treatment of acute variety of jejunogastric intussusception is prompt surgery. Delay in surgery beyond 48 hours is associated with an approximately 50% mortality. At operation if the intussuscepted jejunum is reducible and viable, then simple reduction should be performed. To prevent recurrence the reduced jejunum should be fixed either to the afferent limb of gastrojejunal anastomosis or to the transverse mesocolon. If the bowel is nonviable, then it must be resected. The treatment of chronic recurrent variety of jejunogastric intussusception is symptomatic. If symptoms persist then revisional surgery is performed. Awareness of this complication, early recognition and prompt surgery can reduce the high mortality.
|1.||Bozzi, E.: Annotations. Boll. Acad. Med. 3-4: 122, 1914. |
|2.||Mulero, H.L., Carvalho, H. P. and Knechtges, T.C.: Jejunogastric intussusception-an infrequently recognised cause of postgastrectomy complications. Amer. J. Dig. Dis. 12: 639-645, 1967. |
|3.||Reyelt, W.P., and Anderson, A.A.: Retrograde jejunogastric intussusception, Surg. Gynecol. & Obstet., 119: 1305-1311, 1964. |
|4.||Shackman, R.: Jejunogastric intussusception. Brit. J. Surg., 27: 475-480, 1940. |
|5.||Waits, J. O., Beart, R.W. and Charboneau, W.: Jejunogastric intussusception. Arch. Surg., 115: 1449-1452, 1980 |
|6.||Wolukau-Wanambwa, P.P.: An uncommon cause of haematemesis-retrograde jejunogastric intussusception. Brit. J. Clin. Prac., 33: 53-54, and 58, 1979. |
|7.||Woodard, J.C., Mainz, D.L. and Webster, P.D.: Afferent-efferent loop intragastric intussusception: diagnosed by gastroscopy. Gastroenterology, 64: 120-122, 1973. |