Acute on Chronic Jejuno-gastric Intussusception following Partial Gastrectomy.

Case Report In 1943 Mr. G. A. S. had an antecolic valved Hofmeister partial gastrectomy performed for a high posterior wall gastric ulcer. The operation stood him in good stead for many years but after I 2 years he had an attack of epigastric pain lasting an hour and in the following year he suddenly got another attack after drinking one-and-a-half pints of beer. The pain lasted all night and in the morning he vomited; he thought that the vomit might have contained a little blood. By the time that he reached hospital the pain had begun to ease. On examination there was guarding and rebound tenderness in the epigastrium and bowel sounds were scanty. A plain X-ray of the abdomen failed to reveal any gas under the diaphragm and his symptoms were attributed to peritonism associated with the exacerbation of his chronic bronchitis. He was treated with penicillin and after four days his symptoms had disappeared. Gastroscopy subsequently showed no abnormality. Nineteen years after his gastrectomy (I962) he was again struck down with a severe epigastric pain that came on suddenly whilst he was going for a walk after breakfast. He was able to walk home but the pain, which was unvarying and cramplike, got steadily worse and in the afternoon he was obliged to send for his doctor who thought that he was suffering from a perforated stomal ulcer and arranged for his admission to hospital. When seen at 6.I5 p.m. he was pale and evidently in great pain, but his general condition was good (temperature normal, pulse I io/min., blood pressure 190/70 mm Hg.) and he had not vomited. His abdomen was tendes and rigid in the epigastrium but the lower abdomen was relatively soft. No mass was palpable. Bowel sounds were scanty. Although a perforated stomal ulcer seemed the most probable diagnosis his general appearance did not seem tc be quite right for a patient with a perforated viscus of some ten hours duration, the physical signs were confined to the upper abdomen, and there was no free gas under the diaphragm on radiological examination. Furthermore, there had been no recent historv such as to suggest that he might have a stomal ulcer. As his serum amylase was only 32 units the diagnosis of perforated stomal ulcer was nevertheless allowed to stand and laparotomy was undertaken that evening. Opertation. After opening the abdomen the gastric remnant was picked up so as to be able to feel the stoma and much to our surprise about a foot (30.5 cm.) of afferent jejunum reeled out of the stomach without any assistance beyond the mere lifting up of the latter. The intussuscepted jejunum was perfectly healthy in appearance. There was no stomal ulcer nor any evidence of acute pancreatitis. The afferent loop was about a foot long; it was not involved in the intussusception. The efferent loop could readily be intussuscepted again, indeed it almost gave the impression of preferring to lie in the intussuscepted position. After a little manipulating it was found that it could no longer be intussuscepted if it was held to the greater curvature of the gastric remnant. In an attempt to prevent recurrence the loop was therefore stitched in this position over a distance of about an inch (2.5 cm.) and after making sure that this did not result in any awkward angulation the abdomen was closed. The patient made an uneventful recovery and has remained well since.