Gastrointestinal: Recurrent colic and the percutaneous endoscopic gastrojejunostomy.

Abstract

A 71-year-old lady presented with long-standing colicky epigastric pain and vomiting on a background of advanced Parkinson's disease, treated by third-line medical therapy with duodopa administered by a percutaneous endoscopic gastrojejunostomy (PEG-J) tube. The PEG-J tube provided a steady and constant bioavailability of the drug by overcoming the slow and erratic gastric emptying commonly observed in patients with Parkinson's disease. On examination, the patient was afebrile and hemodynamically stable. She had a soft abdomen with focal epigastric tenderness without peritonism. Her biochemical investigations were unremarkable. Computed tomography scan demonstrated a long segment of thickened small bowel along the PEG-J tubing, with duplicated layers of bowel forming concentric rings consistent with a jejuno-jejunal intussusception (Fig. 1). She underwent a laparotomy demonstrating collapsed proximal loops of jejunum telescoping into distally dilated loops, with a palpable intraluminal mass. Following reduction of the intussusception, a longitudinal enterotomy was performed to deliver a phytobezoar formed over a PEG-J tube knot (Fig. 2). The PEG-J was otherwise well positioned, and no underlying anatomical abnormality was identified. Intussusception is classified according to site of origin: entero-enteric, ileocolic, or colocolic. The vast majority are entero-enteric with jejuno-jejunal intussusceptions being extremely uncommon. Intussusception in adults is almost always due to intraluminal tumors, and rarely are bezoars or PEG-J tubes cited as underlying causes. Unlike children, symptoms in adults are nonspecific, and therefore, abdominal computed tomography is the preferred imaging modality to obtain a diagnosis. Surgery remains the cornerstone of management for adults given the high incidence of intraluminal pathology. Phytobezoars can develop because of a variety of medical pathologies including gastrointestinal motility disorders. Most likely due to her underlying Parkinson's disease, and the rare complication of PEG-J tube knotting, this patient developed a bezoar acting as a lead point causing recurrent intussusception. This case represents an exceedingly rare presentation of a jejunal intussusception secondary to a bezoar forming over a knot in the PEG-J tubing. These images highlight this interesting case, demonstrating the importance of intussusception as a differential diagnosis in patients with nonspecific abdominal complaints, especially those predisposed to gastrointestinal dysmotility, to avoid delays in diagnosis.