Intussusception After Pancreaticoduodenectomy

Abstract

Intussusception in adults is uncommon, accounting for 1-5% of all intussusception cases. We present an exceedingly rare case of retrograde jejunal intussusception into the gastric lumen in a patient with a previous pancreaticoduodenectomy (Whipple procedure). A brief discussion of the management and review of the literature is also presented. A 37-year-old male presented to the emergency department with four days of epigastric abdominal pain and an isolated episode of large-volume hematemesis. Notably, nine months prior, he underwent a Whipple procedure for treatment of a localized neuroendocrine tumor. At presentation, he was hemodynamically stable with a physical exam revealing exquisite diffuse abdominal tenderness without rebound tenderness or distension. Laboratory values were notable for a white blood cell count of 10.4 K/μL and hemoglobin of 13.9 gm/dL. A CT scan of the abdomen/pelvis with oral and intravenous contrast demonstrated a long segment of enteroenteric intussusception in the left abdomen with intussuscepted small bowel extending through the enterogastric anastomosis site and into the residual stomach (Figure 1). Imaging did not reveal a definite lead point. An EGD was performed for further evaluation and to attempt endoscopic reduction. This revealed afferent jejunal loop intussusception of a large segment of bowel (Figure 2) which appeared dusky and erythematous (Figure 3) and contact bleeding concerning for ischemia. The lumen was not found endoscopically and the long intussuscepted loop was not amenable to endoscopic reduction. The patient ultimately underwent an exploratory laparotomy with resection of the gastrojejunostomy and conversion to Roux-en-Y gastrojejunostomy. He recovered without complication and an MRI of the abdomen/pelvis performed two weeks later showed post-surgical changes without evidence of malignancy. Retrograde intussusception after pancreaticoduodenectomy is rare, with only two previously reported cases to our knowledge. While a diagnostic endoscopy may serve to confirm intussusception, identify a potential lead point, and, in some cases, endoscopically reduce the intussusception, surgical management is recommended due to a high rate of recurrence and associated malignancy. Prompt management is required due to the risk of hemorrhage or intestinal necrosis, as demonstrated in our patient.2527_A Figure 1. CT with enteroenteric intussusception extending into the residual stomach.2527_B Figure 2. Afferent jejunal loop intussusception of a large segment of bowel.2527_C Figure 3. Intussuscepted bowel with dusky and erythematous appearance.