AJR 2001; 177:624-626
© American Roentgen Ray Society
Intussusception into the Enteroanastomosis After Billroth II Gastrectomy and Roux-en-Y Jejunostomy
Sonographic and CT Findings
Nancy Hammond1,
Frank H. Miller1 and
Mary Dynes2
1
Department of Radiology, Northwestern Memorial Hospital, Northwestern
University Medical School, 676 N. St. Clair St., Ste. 800, Chicago, IL
60611.
2
Department of Radiology, Fairview Hospital, 18101 Lorain Rd., Cleveland, OH
44111.
Received December 11, 2000;
accepted after revision March 14, 2001.
Address correspondence to F. H. Miller.
Introduction
Intussusception is a rare complication in patients with prior gastric
surgery that was first reported in 1917, 30 years after the first
gastrojejunostomy [1]. Most
reported cases describe retrograde gastrojejunal intussusception with the
efferent loop invaginating into the stomach. We report a patient with a rare
variation of this complication after gastric surgery who had an
intussusception of the jejunal loops into the jejunum through the small bowel
anastomosis, for which the sonographic and CT findings were well
visualized.
Clinical History
A 38-year-old woman presented with the acute onset of severe abdominal
pain, nausea, and hematemesis. The pain began approximately 18 hr before
presentation and was localized to the mid abdomen just below the umbilicus.
Surgical history was pertinent for subtotal gastrectomy, vagotomy, and
Roux-en-Y anastomosis as a result of peptic ulcer disease that occured 2 years
before presentation. After the patient was admitted, a palpable mid abdominal
mass was noted that measured approximately 10 cm. Repeated physical
examinations showed increasing abdominal pain and tenderness.
Sonographic examination showed an approximately 10-cm complex mass with
central hyperechogenicity and a peripheral ring of decreased echogenicity
located inferior to the level of the umbilicus. The mass had sonographic
findings suggestive of an intussusception (Figs.
1A and
1B). CT examination 4 hr later
showed marked dilatation of the stomach and the small bowel loops to the level
of the jejunum. At this level, a large masslike density extended over a long
segment of jejunum, and fat density was present centrally. Additionally,
enhancing vessels were noted centrally within the mass. These findings are
consistent with an intussusception (Figs.
1C and
1D). No pneumatosis or free air
was identified.
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Fig. 1A. —38-year-old woman with severe abdominal pain, nausea, and
hematemesis due to intussusception. Transverse sonogram shows large complex
mass with mushroom appearance, representing intussusceptum that is surrounded
by hypoechoic outer layer, the intussuscipiens (arrows).
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Fig. 1B. —38-year-old woman with severe abdominal pain, nausea, and
hematemesis due to intussusception. Longitudinal sonogram reveals hypoechoic
and hyperechoic portions, representing alternating layers of mucosa, bowel
wall, and mesenteric fat. Intussusceptum is composed of mesenteric fat
(arrow) and collapsed bowel and is surrounded by hypoechoic outer rim
(intussuscipiens).
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Fig. 1C. —38-year-old woman with severe abdominal pain, nausea, and
hematemesis due to intussusception. Contrast-enhanced CT scan obtained 4 hr
after sonography shows complex mass with central fat attenuation and enhancing
foci representing intraluminal mesenteric fat (white arrow). Note
enhancing mesenteric vessels (black arrow) centrally within
intussuscipiens. Also note that proximal small bowel is dilated.
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Fig. 1D. —38-year-old woman with severe abdominal pain, nausea, and
hematemesis due to intussusception. Contrast-enhanced axial CT scan reveals
intraluminal mesenteric fat of intussusceptum (arrow).
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At surgery, a large intraabdominal mass was found that was caused by
intussusception of the small bowel. Approximately 60 cm of intussuscepting
bowel was identified extending proximally through the side-to-side Roux-en-Y
small-bowel anastomosis. After reduction, the intussuscepted segment appeared
ischemic and nonviable and was resected. An end-to-end anastomosis of the
resected segments and a side-to-side serosal approximation of the Roux-en-Y
limb were performed to prevent recurrent intussusception. The patient did well
after surgery, with no complications.
Discussion
Postoperative intussusception is a rare complication after
gastrojejunostomy, Billroth II partial gastrectomy, gastrojejunostomy, and
Roux-en-Y anastomosis. The reported incidence is approximately 0.1%
[2]. Classically, jejunogastric
intussusceptions are categorized into four anatomic variants. Type I is an
antegrade intussusception of the afferent limb. Type II is an efferent loop
invagination and is the most commonly observed type, accounting for
approximately 75% of intussusceptions related to prior gastric surgery
[3]. Type III is a combination
of types I and II with intussusception of the efferent and afferent limbs.
Type IV consists of an intussusception through a side-to-side jejunojejunal
anastomosis [4]. Our patient
had an intussusception involving the distal small bowel through the Y segment
of the Roux-en-Y anastomosis that is best classified as a type IV. Conklin and
Markowitz [5] reported only
seven cases of intussusception occurring through an enteroanastomosis after
gastrectomy in a series of 114 patients.
Clinically, postoperative intussusception can present acutely or
chronically. Acute presentation is characterized by the sudden onset of
epigastric abdominal pain, emesis with or without hematemesis, and a palpable
and tender abdominal mass. A palpable mass is reported in approximately 50% of
cases [6]. In patients with
chronic intussusception, symptoms include vague epigastric pain that worsens
with eating, nausea, and vomiting. Symptoms typically resolve with spontaneous
reduction. In the acute setting, early diagnosis is critical because of the
risk of bowel infarction and associated high mortality.
The pathogenesis of intussusception in patients with a history of prior
gastric surgery is unknown. The most commonly accepted theory is that
antegrade or retrograde peristalsis leads to intussusception of the afferent
or efferent limb. Other theories include mechanical causes such as increased
intraabdominal pressure, adhesions resulting from laparotomy, or derangements
in the stomal function [5].
The diagnosis of acute intussusception can be determined with multiple
imaging modalities, including sonography, CT, and barium studies. The
diagnosis of chronic intussusception is more difficult because of its
intermittent nature. Sonographic evaluation of intussusception classically
reveals an echogenic center surrounded by concentric echogenic rings with a
peripheral rim of hypoechogenicity. On transverse images this rim has been
described as the doughnut sign, and on longitudinal images, as the
pseudokidney sign. CT features of intussusception include a soft-tissue mass
with a "sausage" or target appearance. Additionally, a
crescent-shaped, eccentric, low-attenuation component representing the
entrapped mesenteric fat is typically present. Enhancing foci may be present
centrally in the mass and represent mesenteric vessels. The presence of
intramural air suggests ischemia or infarction but can, at times, be difficult
to distinguish from intraluminal air.
In the acute setting, treatment is typically surgical. Early diagnosis is
critical because mortality rates increase abruptly with surgical delay.
Reported mortality ranges from 10% for treatment within the first 48 hr to 50%
with a 96-hr delay [7]. Once
the diagnosis of intussusception is made, surgical findings guide the
operative procedures performed, which range from reduction with correction to
resection in cases of ischemia or infarction.
Conclusion
Intussusception is a rare complication after gastric surgery with an
incidence estimated at 0.1%. Intussusception of the distal small bowel through
the jejunojejunal anastomosis is even less common. Radiologists' awareness of
this entity and early diagnosis are critical to prevent bowel ischemia and
infarction and to decrease mortality. The diagnosis can be aided by the use of
sonography or CT, as we have shown.
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Introduction
Clinical History
