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Jejunogastric intussusception: a rare complication of a gastrojejunostomy

An 83-year-old lady was referred for a surgical consultation for investigation of abdominal pain and vomiting. She had 12 episodes of bilious vomiting in the preceding 24 h with colicky epigastric pain. Vomiting was associated with temporary resolution of her symptoms. The patient had extensive medical co-morbidities. She had a prior midline laparotomy performed overseas 10 years ago for acute cholecystitis – collateral history from her family suggested that this was complex surgery because of duodenal obstruction caused by her cholecystitis. Physical examination revealed the patient was dehydrated, but haemodynamically normal. Her abdomen was distended with no focal tenderness or masses palpable. Laboratory examinations showed an elevated white cell count (13.7 × 10/L) and new onset renal impairment. Computed tomography (CT) of her abdomen demonstrated a proximal jejunal intussusception that passes through a gastrojejunostomy into the stomach (Fig. 1). A preliminary gastroscopy showed the intussusception prolapsing through the gastrojejunostomy into the stomach (Fig. 2). A midline laparotomy confirmed a jejunal intussusception involving the efferent limb extending proximally through the gastrojejunostomy (Fig. 3). The laparotomy confirmed that a simple gastrojejunostomy had previously been constructed with no gastric resection. The intussusception was reduced and a 20-cm segment of small bowel distal to the gastroenterostomy was resected after no lead point was identified. Recovery was slow, but unremarkable. Histopathological assessment showed changes consistent with acute ischaemia; however, there were no small bowel lesions or lead point identified. Jejunogastric intussusception is a recognized complication of gastroenterostomy formation. Occurrence is rare with a rate estimated at less than 0.5%. The first case was described by Bozzi in 1914. The aetiology is unclear and may be due to a combination of disordered motility and mechanical factors, such as adhesions and a long small bowel mesentery. Intussusception can occur many years following initial surgery, in our case it was 10 years between gastrojejunostomy formation and presentation with intussusception; there are documented cases occurring up to 55 years after surgery. In the acute setting the patient typically presents with colicky epigastric pain and vomiting. Further imaging using CT or ultrasound of the abdomen can assist in making a diagnosis. Features that may be seen on CT include gastric dilatation, a target sign (where