Retrograde jejuno-gastric intussuseption: a rare cause of intestinal obstruction after gastrojejunostomy.
CASE PRESENTATION: A 55 year old male was referred to our centre with primary complaints of pain in abdomen since 8 days, bilious vomiting for 6 days, not passing flatus and stools for 3 days. The patient complained of acute spasmodic pain mainly in the left hypochondrium and lumbar region. There was no significant medical history at the time of admission. There was history of an operative procedure done 30 years back, the details of which were not available.
On admission the patient was severely dehydrated with a pulse rate of 110/min and a blood pressure of 80/60mm of Hg. On inspection there was a midline scar in the supraumbilical region. Abdominal examination revealed tenderness in the left hypochondrium and lumbar region. A vague mass was palpable in the left upper quadrant. Bowel sounds were absent. On per-rectal examination the rectum was empty with ballooning with no evidence of fresh bleeding or malena. Investigations revealed hemoglobin of 19.2mg/dl, WBC count of 19,000/cumm and Serum Creatinine of 2.11mg/dl. Computed tomography of the abdomen showed an approximately 3.5cms wide opening along the greater curvature of stomach in the antro-pyloric region through which there was herniation of multiple small bowel loops of the ileum along with mesentric vessels. (FIG. 1). However, endoscopy was not performed pre-opertaively.
An exploratory laparotomy was subsequently performed on the patient after giving preoperative antibiotics. Intra-operative findings revealed that the patient had been operated for gastro-jejunostomy (retro-colic and iso-peristaltic). The stomach was grossly dilated. The efferent jejunal loop of the jejuno-gastric anastamosis had undergone intussusception in a retrograde manner into the stomach through the stoma site.
The herniated segment of the jejunum could not be reduced and hence a gastrotomy was performed. (FIG. 2) Approximately 10-15cms of the gangrenous bowel loops were resected. The healthy stump of the efferent segment was anastomosed with the distal jejunum by hand sewn method. The resultant efferent jejunal loop was fixed to the transverse colon to prevent recurrence. In the post-operative period there was no evidence of anastamotic leakage.
The histopathology report of the operated specimen revealed it as a gangrenous small bowel segment. In the post-operative period the patient remained on ventilatory and inotropic support. Subsequently patient succumbed on the fourth post-operative day as a result of septicemia and acute renal failure.
DISCUSSION: Intussusception is an underappreciated complication of Gastrojejunostomy. In one review of 15, 553 gastric bypass surgeries at a single institution, 23 patients developed a retrograde intussusception.  There is no medical treatment for jejuno-gastric intussusception and surgical intervention is required for definite treatment. Gastrojejunostomy intussusception can be classified into three anatomical types: afferent loop intussusception; efferent loop intussusception or that involving both afferent and efferent loops. 
Two forms of jejuno-gastric intussusception 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. The acute form is characterized by sudden severe colicky epigastric pain, vomiting and subsequently, hematemesis. Epigastric tenderness and a palpable abdominal mass can be observed in about 50% of cases and signs of small bowel intestinal obstruction can also be found. [6,7,8] In the chronic form, the diagnosis is difficult. The main reason for this is that upper GI endoscopy must be performed during the symptomatic period for the diagnosis to be confirmed. 
The etiology of Jejuno-gastric intussusception is still not clear. The most likely hypothesis is disordered motility with functional hyper peristalsis triggered by spasm or hyperacidity. Mechanical factors include adhesions, long mesentery and a sudden increase in abdominal pressure. Intussusception of gastro-jejunostomy is more often retrograde. The classical triad of jejuno-gastric intussusception includes sudden onset of epigastric pain, vomiting with or with-out hematemesis and a palpable epigastric mass with past history of gastric surgery.  Although computed tomography is the most reliable investigation, endoscopy performed by someone familiar with this rare entity, is certainly diagnostic. [10,11]
Treatment of jejuno-gastric intussusception involves prompt surgery. If the intussuscepted bowel loop is viable and reducible, then simple reduction is performed. To prevent recurrence the reduced jejunal loop can be fixed either to the afferent loop or the transverse colon. If the bowel loop is not viable it should be resected and the continuity with the distal segment should be established.
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[3.] Hasan M, Mahamud MM, Khan SA, Rahman M. Jejunogastric intussusception. Mymensingh Med J. 2009; 18 (2):255-9.
[4.] ShackmanR. Jejunogastric intussusception. Br. J Surg. 1940; 27: 475-480.
[5.] Sibley WL. Chronic intermittent intussusception through the stoma of a previous gastroenterostomy. Proc Staff Meet Mayo Clin. 1934; 9 : 364-365.
[6.] Waits JO, Beart RW Jr, Charboneau JW: Jejunogastric intussusception. Arch Surg 1980; 115: 1449-1452.
[7.] White TT, Harrison RC, Reoperative Gastrointestinal surgery. Little Brown and Company, 1973. P. 98.
[8.] Foster Dg, Retrograde Jejunogastric Intussusception--a rare cause of hematemesis. AMA Arch Surg. 1956; 73: 1009-1017.
[9.] Jaaskelainen V. Retrograde intussusception after certain gastric operation. Ann Chir Gynaecol. 1954; 5 (Suppl):129-135.
[10.] Kallen R, GraffnerH, Jonsson Per-Ebbe J. Jejunogastric Intususception through the enteroanastomosis after gastric resection. Case report. ActaChir Scand. 1986; 152: 637-640.
[11.] Truong SN, Tittel A, Schumpelick V. Die jejunogastrische Invagination-eineseltene Komplikation der Magenchirurgie. Z Gastrenterol. 1992; 30:798-800.
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(1.) Bharat R. Saxena
(2.) Rajesh C. Mahey
(3.) Rajesh G. Patil
(4.) Parag L. Sonawane
PARTICULARS OF CONTRIBUTORS:
(1.) Post Graduate Student, Department of General Surgery, TN Medical College and BYL Medical College, Mumbai.
(2.) Associate Professor, Department of General Surgery, TN Medical College and BYL Nair Hospital, Mumbai.
(3.) Assistant Professor, Department of General Surgery, TN Medical College and BYL Nair Hospital, Mumbai.
(4.) Post Graduate Student, Department of General Surgery, TN Medical College and BYL Nair Hospital, Mumbai.
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Bharat R. Saxena, #B-301, Ivy Towers, Vasant Valley, Ge A. K. Vaidya Marg, Malad (East), Mumbai-400097.
Date of Submission: 18/04/2014.
Date of Peer Review: 19/04/2014.
Date of Acceptance: 20/05/2014.
Date of Publishing: 02/06/2014.
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|Title Annotation:||CASE REPORT|
|Author:||Saxena, Bharat R.; Mahey, Rajesh C.; Patil, Rajesh G.; Sonawane, Parag L.|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Date:||Jun 2, 2014|
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