Jejunogastric intussusception.

Abstract

Gastrojejunostomy, alone or in combination with gastric resection, is occasionally followed by intussusception of the jejunum through the stoma into the stomach. Two such cases were encountered recently at the Cincinnati General Hospital and form the basis of the present report. The first case of jejunogastric intussusception was reported by Bozzi (5) in 1914. This was lost in the literature and subsequent authors cited Steber as having made the initial report in 1917. There followed a number of single case reports, so that in 1933 Bettman and Baldwin (3) were able to summarize the clinical findings in 33 cases. In 1924, von Brunn (6) published the first roentgenogram of the condition. The radiological features were later clearly described by Ledoux-Lebard and Garcia-Calderon (26) and Gutmann and Jobin (20). Aleman (2), in 1948, found 70 cases reported in the literature and added 2 of his own. Over 100 cases have been recorded up to the present writing. Four types of jejunogastric intussusception have been encountered (Fig. 1). Most common by far is intussusception of the efferent loop of the gastrojejunostomy. Intussusceptions of the afferent loop and of both the afferent and efferent loops occur less often and are of about equal frequency. In Aleman's series the incidence was 74, 10, and 15 per cent, respectively. At least 7 cases of intussusception following subtotal gastrectomy have been reported (2, 18, 25, 29, 44, 45). Clinical symptoms and signs are either of the acute or chronic type. In the acute form, which is much more frequently reported, there is usually colicky abdominal pain, nausea, and vomiting of bile-stained material. If the bowel remains incarcerated and becomes gangrenous, the vomitus usually becomes bloody. In 19 of the 70 cases reviewed by Aleman, an epigastric mass was palpable. A mistaken diagnosis of mechanical bowel obstruction or bleeding ulcer is usually made. In such cases, if medical management is instituted, the patient's life is jeopardized, the mortality then approaching 100 per cent. In the chronic type, periodic attacks of abdominal pain, nausea, and vomiting may occur over a period of years. The symptomatology varies depending upon the degree of obstruction and, according to some authors (20), upon whether the afferent or efferent loop is involved. The correct diagnosis is rarely made clinically. The diagnosis is based on the roentgen findings. A circumscribed intraluminal defect in the stomach, the outer surface of which shows the concentric striations of valvulae conniventes, in a patient who has had a gastroenterostomy is pathognomonic. The appearance of the filling defect varies with the length of the protruding intestinal segment, the amount of barium given, and the degree of pressure made when taking spot films.