Retrograde jejuno-gastric intussuception

Clinical History

A 50-year-old male patient with chronic alcohol overconsumption, presented with the complaint of recurrent blood-stained vomits for the past month. His general examination was insignificant. No icterus was present. His blood profile and liver function test were within normal limit. In retrospect, the patient had a history of previous surgery for gastric perforation.

Imaging Findings

Contrast-enhanced computed tomography (CECT) with oral contrast showed the loop of jejunum along with its mesentery encroaching into the gastric lumen.

Discussion

Intussusception is the invagination of a bowel loop (intussusceptum) into the lumen of a contiguous portion of bowel (intussuscipiens). Typical “bowel-within–bowel” loop has been described on imaging for diagnosis of intussusception. RJGI is a rare abdominal condition where the jejunal loop is inverted and invaginates into the gastric lumen. It is usually a complication of gastrojejunostomy or partial gastrectomy with an incidence of 0.1% [1, 2], as first described by Bozzi in 1914 [3]. Long afferent loop, jejunal spasm or atonic stomach with abnormal motility, increased mobility of the efferent loop, surrounding adhesions, increased intra-abdominal pressure, and retrograde peristalsis have been described as possible mechanism for development of RJGI [2].
Acute gastrointestinal bleeding is a potentially life-threatening abdominal emergency. Most common causes of upper gastrointestinal bleeding are ulcerative disease of the stomach and/or duodenum and gastroesophageal varices. However, in our case imaging finding of mass-like projection into the gastric lumen point towards any gastric tumour or foreign body i.e. bezoar. Crest syndrome, Dieulafoy's lesion, Mallory-Weiss syndrome, rupture of an aneurysm of the branches of the coeliac artery or superior mesenteric artery, aortoenteric fistula, Crohn's disease, parasitic infestation are some of the rare causes of UGI bleed [4].
According to the type of intussuscepted loop, Shackman R [5] classified jejuno-gastric intussusception into three types: type I, antegrade or afferent loop intussusception; type II, retrograde or efferent loop intussusception (80%); and type III, combined form. Antegrade ileocolic intussusception is the most common type (77%) with retrograde being the least common. These usually presents with history of red currant jelly stool [6]. RJGI is a rare occurrence as a cause of UGI bleed. Two different forms of RJGI have been described according to its clinical presentation [7]. In the acute form usually complicated by incarceration and strangulation of the intussuscepted loop causing severe epigastric pain, vomiting and haematemesis. However, spontaneous reduction is usual in the chronic type. A mortality rate of 10% and even as high as 50% has been reported if surgical intervention was delayed [3, 8].
This case highlights the fact that whenever a patient has had previous gastric surgery and presents with acute GI bleeding, RJGI is one of the diagnoses that should be looked for.
Surgical options include only reduction or resection of the compromised bowel with revision of the anastomosis.

Differential Diagnosis List

Final Diagnosis

Retrograde jejuno-gastric intussusception (RJGI)

URL:	https://www.eurorad.org/case/13354
DOI:	10.1594/EURORAD/CASE.13354
ISSN:	1563-4086