Journal of Emergencies, Trauma, and Shock
Home About us Editors Ahead of Print Current Issue Archives Search Instructions Subscribe Advertise Login 
Users online:369   Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size   


 
CASE REPORT Table of Contents   
Year : 2010  |  Volume : 3  |  Issue : 4  |  Page : 406-408
Jejunogastric intussusception presenting as tumor bleed


Department of General Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir - 190 011, India

Click here for correspondence address and email

Date of Submission02-Dec-2009
Date of Acceptance30-Apr-2010
Date of Web Publication28-Sep-2010
 

   Abstract 

Jejunogastric intussusception (JGI) is a rare but serious complication of previous gastrectomy or gastrojejunostomy, and a delayed diagnosis can lead to catastrophe. It can present as hematemesis, and an endoscopist aware of the condition can diagnose it early. We present a case of JGI presenting as hematemesis and diagnosed as tumor bleed on endoscopy. Diagnosis of JGI was confirmed on laparotomy, gangrenous efferent limb was resected and a fresh gastrojejunostomy performed.

Keywords: Gastrectomy, jejunogastric, intussusception

How to cite this article:
Rather SA, Dar TI, Wani RA, Khan A. Jejunogastric intussusception presenting as tumor bleed. J Emerg Trauma Shock 2010;3:406-8

How to cite this URL:
Rather SA, Dar TI, Wani RA, Khan A. Jejunogastric intussusception presenting as tumor bleed. J Emerg Trauma Shock [serial online] 2010 [cited 2019 May 26];3:406-8. Available from: http://www.onlinejets.org/text.asp?2010/3/4/406/70775



   Introduction Top


Jejunogastric intussusception (JGI) is a rare complication of partial gastrectomy or gastrojejunostomy with no medical treatment, [1] and it can occur any time after the gastric operation. [2] When the operation is performed within 48 hours, a mortality of 10% is reported, and as high as 50% mortality can occur when the surgery is delayed beyond 48 hours. [3] The characteristic triad of acute JGI includes sudden onset of epigastric pain, vomiting with or without hematemesis and a palpable epigastric mass (seen in 50% only). [4] The chronic form of JGI is characterized by milder, intermittent symptoms which usually resolve spontaneously. Less than 200 cases of retrograde JGI have been reported, [5] and only one such case has been reported as tumor bleed, to the best of our knowledge. [6]

The aim of our report is to highlight the possibility of JGI as a differential diagnosis of tumor bleed in a gastric surgery patient.


   Case Report Top


A 65-year-old male patient presented to our emergency department with epigastric pain and vomiting for 2 days and hematemesis for 1 day. He had vomited almost 1.5-2 l of blood over the last 24 hours (the vomited blood was preserved by the attendants in a bowl) before presentation. There was history of diarrhea with melina, a sample of which was presented by the attendants in casualty. Previous records revealed that a retro colic gastrojejunostomy with truncal vagotomy was performed 15 years back for peptic ulcer disease. On examination, the patient was pale with a pulse rate of 96 beats per minute (bpm) and blood pressure (BP) of 100/60. A tender, firm epigastric mass was palpable. Laboratory investigations revealed a hemoglobin (HB) of 7.8 g/dl, total leukocyte count (TLC) of 15,000 with 90% neutrophills. Coagulogram, platelet count and serum creatinine were normal. Two large bore intravenous access lines were established, nasogastric tube inserted, and the patient was catheterized. The patient was being resuscitated by crystalloids and blood transfusions to gain time for upper gastrointestinal (GI) endoscopy. X-ray abdomen was done during the process of resuscitation, which was grossly normal. USG abdomen revealed stomach full of echogenic material (blood). After stabilization, the patient was taken for upper GI endoscopy which revealed findings suggestive of a bleeding gastric tumor with stomach full of clots. The bleeding was not controlled by endoscopic measures, and the patient was taken for emergency laparotomy. On laparotomy, efferent limb of jejunum was intussuscepting into the stomach [Figure 1]. Gastrotomy was performed along the greater curvature on the anterior surface of the stomach. The pooled blood and clots were wiped out and the intussuscepted gangrenous efferent jejunal limb was revealed as a mass [Figure 2]. About 25 cm of the gangrenous intussuscepted efferent limb of jejunum [Figure 3] was resected from the stomach, and its stump was closed flush with stomach wall after everting it. Ryle's tube was passed through antrum, duodenum and back into the stomach through the previous gastrojejunostomy to identify the afferent limb. A fresh anti colic, side to side gastrojejunostomy was performed along the greater curve using the gastrotomy incision. The postoperative period was uneventful and the patient was discharged on 7 th postoperative day. Histopathologic examination of the resected bowel showed features of necrosis. He is on our regular follow up and is asymptomatic since the last 6 months.
Figure 1: Intussuscepting the efferent jejunal limb into the stomach before gastrotomy incision is made

Click here to view
Figure 2: Gangrenous intussuscepted jejunum inside the stomach through gastrotomy incision. The intussusceptum is bleeding and is mimicking a bleeding gastric tumor

Click here to view
Figure 3: Gangrenous intussuscepting jejunum is delivered out of the gastrotomy incision for resection

Click here to view



   Discussion Top


At the Mayo Clinic in a period of 72 years (1907-1980) years, only 16 well documented cases of JGI have been recognized. [5] Jejunojejunal or jejunoduodenal intussusception has been reported after total gastrectomy, and one case of duodenogastric intussusception has been reported after Billroth I gastrectomy. [5] Shackman described three anatomical variants of JGI. In type I, the afferent loop is intussuscepted into the stomach. In type II, the efferent loop is intussuscepted, and type III represents a combined form. It has been stated that type II is the most common (80%). [7] In our case, a type II JGI was documented on operation, with a long gangrenous jejunal segment inside stomach mimicking a bleeding gastric tumor.

Various factors have been incriminated in the etiology of JGI, such as hyperacidity, long afferent loop, jejunal spasm with abnormal motility, increased intra-abdominal pressure, increased motility of efferent loop, adhesions leading to intussusception of a more mobile segment into fixed segment, widening of upper jejunum, vomiting, pregnancy, labor and other causes of increased intra-abdominal pressure, dilated atonic stomach and retrograde peristalsis. [8] Retrograde peristalsis which can occur in normal people prior to gastric surgery, seems to be accepted as the cause of type II JGI by most authors. [1]

A patient with chronic JGI may present with recurrent episodes of abdominal discomfort which may be associated with nausea that is exacerbated by food, and usually subsides after a couple of hours. [9] In many such patients, the correct diagnosis has never been established. The main reason for this is that upper GI endoscopy must be performed during the symptomatic period, for the diagnosis to be confirmed. However, it has been suggested that in the asymptomatic period, the provocation of JGI during endoscopy by the use of a jet of water directed toward the anastomotic stoma may be diagnostic of the chronic form. [5] Computed tomography shows the classical "target". [10] However, we could not perform this investigation because the patient was bleeding continuously, and he was taken for emergency laparotomy.

Emergency surgery is the only answer in acute JGI, and various options include reduction of the limb, resection, take-down of the anastomosis, and revision of the anastomosis. [1] Stefano et al., in a similar case, tried endoscopic reduction of the intussuscepting limb but did not succeed. [11] Jain et al. reported four cases of acute type II JGI. They were able to reduce the intussusceptum in three cases and in situ resection of the gangrenous jejunum was performed in one case. They recommended in situ resection as the method of choice in case gangrenous intussusceptum is found. [12] We resected the gangrenous limb in situ and performed another gastrojejunostomy utilizing the gastrotomy incision. Future recurrence of JGI can be prevented by anchoring the involved jejunal segment to either the neighboring jejunal limb or to the transverse mesocolon. [9]


   Conclusion Top


We conclude that JGI with gangrenous, bleeding intussusceptum can mimic a bleeding gastric tumor, and high index of suspicion regarding JGI is needed in an operated case of gastrojejunostomy or gastrectomy, with a palpable epigastric mass.

 
   References Top

1.Waits JO, Beart RW, Charboneau JW. Jejunogastric intussusception. Arch Surg 1980;115:1449-52.  Back to cited text no. 1      
2.Conklin EF, Markowitz AM. Intussusception-a complication of gastric surgery. Surgery 1965;57:480-8.  Back to cited text no. 2  [PUBMED]    
3.Shackman R. Jejunogastric intussusception. Br J Surg 1940;27:475-80.  Back to cited text no. 3      
4.Foster DG. Retrograde jejunogastric intussusception - a rare cause of hematemesis. A M A Arch Surg 1956;73:1009-17.  Back to cited text no. 4      
5.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. 5  [PUBMED]  [FULLTEXT]  
6.Munteanu M, PξrΊcoveanu M, Mγnescu P, BiciuΊci V, Petrescu F, Munteanu MC, et al . Intussusception of efferent intragastric loop after gastrojeju. n exceptional cause of high occlusion and hematemesis. Chirurgia (Bucur) 2006;101:525-8.   Back to cited text no. 6      
7.Reyelt WP, Anderson AA. Retrograde jejunogastric intussusception. Surg Gynecol Obstet 1964;119:1305-11.  Back to cited text no. 7      
8.Bakhash K, Igbinovia A, Egere JU, Ali A, Butt MS, Rehan AM. Jejunogastric intussusception: a rare cause of life threatening hematemesis. Ann Saudi Med 1997;17:328-30.  Back to cited text no. 8      
9.Prasad S, Ramachandra L, Deepak S. Gangrenous Jejunogastric Intussusception. Internet J Surg 2009. p. 19.   Back to cited text no. 9      
10.Vohra P, Arora A, Parikh N, Vaghani M, Vaghela P, Vaidya V, et al. Retrograde Jejunogastric Intussusception. Indian J Radiol Imag 2005;15:493-5.  Back to cited text no. 10      
11.Guadagni S, Pistoia M, Catarci M, Carboni F, Lombardi L, Carboni M. Retrograde jejunogastric intussusception: Is endoscopic or surgical management more appropriate. Surg Today 1992;22:269-72.  Back to cited text no. 11  [PUBMED]    
12.Jain BK, Lodh U, Chandra SS, Hadke NS, Ananthakrishnan N, Mehta RB, et al. Jejunogastric intussusceptions: Therapeutic options. Aust N Z J Surg 2008;59:865-8.  Back to cited text no. 12      

Top
Correspondence Address:
Tanveer Iqbal Dar
Department of General Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir - 190 011
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.70775

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3]

This article has been cited by
1 Retrograde jejunogastric intussusception: A case report and review of the literature
Chao-Man Loi,Shu-Yi Huang,Ying-Da Chen,Shian-Dian Chen,Jiann-Ming Wu,Kuo-Hsin Chen
Asian Journal of Surgery. 2014;
[Pubmed] | [DOI]
2 Jejunogastric intussusception: a rare cause of gastric outlet obstruction
Ahmet Pergel,Remzi Adnan Akdogan,Ibrahim Aydin,Ahmet Fikret Yucel,Ibrahim Sehitoglu,Dursun Ali Sahin
ANZ Journal of Surgery. 2013; : n/a
[Pubmed] | [DOI]



 

Top
 
  Search
 
  
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Introduction
    Case Report
    Discussion
    Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed4441    
    Printed153    
    Emailed1    
    PDF Downloaded20    
    Comments [Add]    
    Cited by others 2    

Recommend this journal