Jejunogastric intussusception presented with hematemesis: a case presentation and review of the literature
© Archimandritis et al; licensee BioMed Central Ltd. 2001
Received: 5 December 2000
Accepted: 4 January 2001
Published: 4 January 2001
Jejunogastric intussusception (JGI) is a rare but potentially very serious complication of gastrectomy or gastrojejunostomy. To avoid mortality early diagnosis and prompt surgical intervention is mandatory.
A young man presented with epigastric pain and bilous vomiting followed by hematemesis,10 years after vagotomy and gastrojejunostomy for a bleeding duodenal ulcer. Emergency endoscopy showed JGI and the CT scan of the abdomen was compatible with this diagnosis. At laparotomy a retrograde type II, JGI was confirmed and managed by reduction of JGI without intestinal resection. Postoperative recovery was uneventful.
JGI is a rare condition and less than 200 cases have been published since its first description in 1914. The clinical picture is almost diagnostic. Endoscopy performed by someone familiar with this rare entity is certainly diagnostic and CT-Scan of the abdomen could also help. There is no medical treatment for acute JGI and the correct treatment is surgical intervention as soon as possible.
Jejunogastric intussusception (JGI) is a rare complication of gastrectomy or gastrojejunostomy which can occur any time after the gastric operation. Early diagnosis of this condition and prompt surgical intervention is mandatory: a mortality of 10% and even as high as of 50% has been reported if operation has been performed 48 h or later after the onset of severe symptoms, respectively[3,4]. Emergency endoscopy, carried out by endoscopists aware of this condition and its endoscopic picture, can put the correct diagnosis very soon. We describe a young patient with JGI, who was admitted to the hospital with the diagnosis of upper gastrointestinal (GI) bleeding. JGI was subsequently diagnosed by an emergency upper GI endoscopy.
Jejunogastric intussusception (JGI) was described in 1914 by Bozzi in a patient with gastrojejunostomy. Eight years later this complication was also reported in a patient with Billroth II resection. Subsequently, a large number of isolated cases and small series have been published and the reviews of the literature showed that less than 200 cases have been reported[1,2,7,8,9,10]. Thus, JGI seems to be a rare complication after gastrojejunostomy or Billroth II gastrectomy; it also has been described rarely in association with previously placed gastrostomy tubes.
Occasionally, jejunojejunal or jejunoduodenal intussusception have been observed after total gastrectomy[12,13,14] and one case of duodenogastric intussusception after Billroth I gastrectomy. It is interesting to point out that only 16 well-documented cases have been recognized at the Mayo Clinic in a period of 72 (1907-1980) years. Three anatomic types of JGI have been described: type I concerns the afferent loop, type II the efferent loop and type III represents a combined form. It has been stated that type II or retrograde efferent loop intussusception is the most common (80%) with the two other types accounting for 10% each. In the case presented, a type II JGI was documented.
There is a wide variation in the lapse time between the gastric operation and the JGI to occur: 6 days to 20 years and 8 days to 19 years in patients with gastroanastomosis and partial gastrectomy respectively. Ten years was the lapse time in the present case. The cause(s) of JGI is poorly understood. Various factors have been incriminated such as hyperacidity, long afferent loop, jejunal spasm with abnormal motility, increased intra-abdominal pressure, retrograde peristalsis etc. Probably, 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[1,16].
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 occur whilst spontaneous reduction is usual in the chronic type. Thus, the acute form is characterized by acute severe colicky epigastric pain, vomiting and, subsequently, hematemesis. Epigastric tenderness and a palpable abdominal mass can be observed in about 50% and signs of high intestinal obstruction can also be found[1,17,18]. It should be pointed out that a sudden onset of epigastric pain, vomiting and subsequent hematemesis, and a palpable epigastric mass in a patient with a previous gastric surgery are thought as the classic triad of JGI. The picture was absolutely typical in the case described here. In the chronic form, the symptoms may be roughly similar to the acute form but milder, transient and subside spontaneously.
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- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/content/backmatter/1471-230X-1-1-b1.pdf
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