K Bakhsh, A Igbinovia, JU Egere, A Ali, MS Butt, AM Rehan, Jejunogastric Intussusception: A Rare Cause of LifeThreatening Hematemesis. 1997; 17(3): 328-330 An intussusception is an invagination of a segment of gastrointestinal tract into an adjacent one. It is a rare cause of intestinal obstruction in adults, compared to children, in whom it is second only to appendicitis as a cause of abdominal emergency.1,2 Whereas intussusception is usually idiopathic in children, in adults an underlying pathology is demonstrable in over 90% of cases.3 The intussusception is located in the large or small intestine in 90% of cases and in the stomach or surgically created stomas in the remaining 10%. 4 Jejunogastric intussusception (JGI) is a very difficult condition to diagnose. Its rarity necessitates a high index of suspicion if cases, particularly the chronic recurrent type, are not to be missed.We report a case of acute JGI presenting with severe hematemesis.
Case ReportA 60-year-old Saudi man presented with abdominal pain and vomiting, which had begun suddenly two hours before admission. Repeated vomiting was followed by hematemesis. The only significant past history was an operation for duodenal ulcer in India 16 years previously, following which he had remained symptom free. The type of operation was not known.On examination, the patient looked ill and anxious. The pulse was initially 75/minute and the blood pressure 150/80. Abdomen was soft, not distended, but tender in the epigastrium. No mass was felt. There were no signs of chronic liver disease. Following further hematemesis the man's blood pressure dropped to 80/50 and he went into shock. After initial resuscitation with six units of blood, intravenous vitamin K and cimetidine, an urgent upper gastrointestinal endoscopy was performed. The stomach revealed a big clot of blood and reddish-brown mass lined by whitish streaks. The antrum ended blindly. The blood clot was not disturbed because of fear of precipitating further bleeding. No specific diagnosis could be made at this stage.The results of investigations were hemoglobin 14. The following day the patient vomited more foul-smelling material mixed with altered blood. Upper gastrointestinal barium study revealed a long tubular filling defect in the antral region of the stomach, showing valvulae conniventes lined with contrast ( Figure 1). A diagnosis of jejunogastric intussusception was made.Upon operating, it was found that a loop of small intestine was intussuscepting into the stomach through an antecolic anastomosis. The lead point was a hypertrophied lymph node with an adhesive band.The intussusception was reduced manually. A gastrostomy did not reveal any stomal ulcer. The bleeding was presumed to be from congested mucosa. Histology of the excised lymph node showed only reactive lymphadenitis.
DiscussionJejunogastric intussusception is a rare complication of gastrojejunostomy, Billroth II gastrectomy and Roux-en-Y gastrectomy.
In a five-year case-control study (1988 to 1993) at Assir Central Hospital (ACH), Abha (8,000 feet above sea level), Saudi Arabia, 92 of 129 patients suspected of deep venous thrombosis (DVT) were studied with ascending contrast venography (CV) (74 patients, 80.4%) or Doppler ultrasonography (DUS) (18 patients, 19.6%). Female-to-male ratio was 2.3 to 1. Age range of patients was twelve to ninety years; mean age was 44.45 yrs +/- 17.38 years. DVT hospital incidence was 18 per 10,000 admissions. The most common associated factors included immobilization due to chronic diseases (21.7%), trauma and surgery (19.6%), and pregnancy and oral contraceptives usage (16.3%). The most common symptom and sign were limb pain and tenderness (95.6%). Limb swelling was noted in 93.5% of patients. The left lower limb was more commonly affected than the right. There was a definite increase of DVT during the winter months. Altitude was not a contributory factor. Pulmonary embolism was the greatest complication.
Two autochthonous cases of kala-azar, the first such report of the disease from Central and Southern Africa, are described. Both patients presented with generalized macules, papules and nodules without ulceration and both also had tuberculosis. Amastigotes were cultured from blood and identified in skin, bone marrow, liver and spleen.
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