VOL. XXII, No.

261

JEJUNO-GASTRIC INTUSSUSCEPTION
By D. M. COATES, M.B., Ch.B.,

D.M.R.D.

Radiologist, Stockport Infirmary and Crewe Memorial Hospital

On examination he was tender in the hypochondrium
but no masses were felt. He was examined radiologically for
the first time on February 20, when the findings were as
follows:
The stomach emptied through the duodenum and the
duodenal cap was deformed but not tender. No enterostomy
stoma was demonstrated and there was no gastric stasis,
dilatation, or duodenal ileus. On compression two partially
mobile filling defects were present in the body of the
stomach towards the greater curve, which showed a concentric mucosal pattern and a relatively clear cut outline.
The diagnosis rested between a jejuno-gastric intussusception and benign polypoid tumours, the former being more
likely because of the characteristic mucosal pattern and the
similarity of the two filling defects (Figs. 2 and 3).
A gastroscopy was performed on February 25, of which
the report read: "Passed easily, pyloric antrum well seen
and appears normal, the gastro-enterostomy opening was
identified and I think there is still some bulging through of
the jejunum. On the jejunum opposite the gastro-enterostomy opening there was a white patch which was constant
through the examination, but no edge could be seen, so I

HIS condition was first reported by Von Steber

(1917) in Germany. Shackman (1940), in a
review of the literature, found 40 cases, to which he
added one of his own. Chamberlin (1940) described
the radiological signs of intussusception of the
jejunum into the stomach, stressing three main
points.
1. The presence within the stomach of a partially
moveable filling defect, having parallel curved
lines simulating the normal pattern of small
intestinal folds.
2. The re-entry of some of the barium which had
left the stomach through the pylorus by way of
the afferent loop and the stoma.
3. Delayed gastric emptying and gastric dilatation.

FIG. 1.
Type 1. Intussusception of afferent loop.
Type 2. Intussusception of efferent loop.
Type 3. Intussusception of both afferent and efferent loops.
Type 4. Intussusception
involving the jejunum immediately approximated to the stomach.

The case to be described fulfilled only the first of

these conditions.
Shackman states that only three types of intussusception may occur. It would, however, seem likely
that to these a fourth must be added; that is, an incomplete intussusception of the efferent and
afferent loops where only the jejunum immediately
approximated to the stomach is involved and the
duodeno-jejunal circle is unobstructed (Fig. 1).
CASE REPORT

T.T., a male, age 56 years, was admitted to hospital on

February 18, 1948, complaining of abdominal pain and
vomiting, which had become worse during the last two
weeks. His appetite was poor but he had only lost a few
pounds in weight. He gave a past history of a perforated
duodenal ulcer in 1918, of which operative findings were
not available. In 1938 he was again in hospital but received
medical treatment only.

can't be sure that it was an ulcer. Nothing else than that

seen, brisk peristalsis at the gastro-enterostomy opening."
The patient was re-examined radiologically several days
later and it was now found that an enterostomy stoma was
working well and the two filling defects previously seen
were considerably less noticeable (Figs. 4 and 5). However,
prior to this examination, the patient had described an
attack of pain which was interpreted as reduction or
attempted reduction of the intussusception.
On March 10 a partial gastrectomy was performed, when
the operative findings were as follows: "On inspecting the
stomach it was seen that there was an old healed duodenal
ulcer not producing stenosis. The gastro-anastomosis was
found to have a very long afferent loop, approximately
7-8 inches; this was disconnected from the stomach and
the jejunum closed. A sub total gastrectomy was performed
in the usual way and presented no difficulty. We then did a
posterior anastomosis."
Although it was not conclusively proved at the
gastroscopy or the operation that a retrograde
intussusception had occurred, I feel that the

544

SEPTEMBER

Jejuno-gastric Intussusception

FIG. 3.
Pressure film of filling defect.

FIG. 2.
The apparently normal duodenal circle and filling defect of
the greater curve.

FIGS. 4 and 5.

The stomach after reduction had taken place.

545

1949

VOL. XXII, No. 261

D. M. Coates
radiological evidence was sufficient to warrant this
diagnosis. It is, however, of interest to note that the
gastric or duodenal dilatation or stasis associated
with the earlier cases did not present itself in the
case discussed.
ACKNOWLEDGMENTS

My thanks are due to Dr. C. S. D. Don, consultant

physician, for permission to use his gastroscopy findings;
and to Mr. Hector Scotson, consultant surgeon, for the use
of his operation notes.

unmittelbar am Magen anliegende Jejunum invaginiert war

und dass daher die Passage via Duoden-Jejunum frei blieb.
RESUMEN

Se describe un caso de intususcepcion yeyuno-gastrica

a traves de un estoma de enteroscopfa. No se hallaba
asociada con dilatacion gastrica, estasis o fleo duodenal. El
que no apareciesen sfntomas de obstruction era debido al
hecho de que el yeyuno complicado era la porcion inmediatamente proxima al est6mago y el cfrculo duodenoyeyunal seguia estando abierto.
REFERENCES
CHAMBERLIN, Amer. Journ. Surg., 1940, xlix, 510.
SHACKMAN, Brit. Journ. Surg., 1940, xxvii, 475.
VON STEBER, Munch. Med. Woch., 1917, xx, 648.

SUMMARY

A case of jejuno-gastric intussusception through an

enterostomy stoma is described. It was not associated with
gastric dilatation, stasis, or duodenal ileus. The nonappearance of obstructive symptoms was due to the fact
that the jejunum involved was that portion immediately
approximated to the stomach and the duodeno-jejunal
circle remained patent.
RESUME

Description d'une invagination jejuno-gastrique a travers

une bouche enteroscopique. La lesion n'etait pas accompagnee de stase, de dilatation gastrique ni d'ileus duodenal.
L'absence de symptomes d'obstruction etait due au fait que
le jejunum invagine etait celui de la portion immediatement
adjacente a l'estomac, et que le circuit duodeno-jejunal
etait reste permeable.
ZUSAMMENFASSUNG

Beschreibung eines Falles von Invagination des Jejunums

in einer Gastro enterostomie durch das Stoma. Es lag keine
Magenerweitaung, Entleerungsverzogerung und kein Duodenalverschluss vor. Der Grund hierfiir war, dass nur das

NOTE

Since this case was submitted for publication,

the Honorary Medical Editor has called my attention to an article published in Ada Radiologica by
Sten Aleman (1948). The author describes a case of
jejuno-gastric intussusception of the efferent loop
(Fig. 1, Type2) in a patient previously subjected to a
Billroth II stomach resection. In a comprehensive
review of the literature, he attributes the first case
to Bozzi in 1914. Since then about 70 cases have
been described, but only 12 cases were diagnosed
radiologically.
ALEMAN,

REFERENCE
S., Ada Rad., 1948, xxix, 383.

REVIEW
Clinical Radiation Therapy. By Ira I. Kaplan, M.D.,
2nd Edition, 1949, pp. 844 (Hoeber, New York),
4 10*.
The first edition of this work appeared in 1937,
one of the first attempts to publish under one cover
the indications for treatment of disease by radiation.
The scope of this second edition is similar. It is
a book written by a teacher in this specialised subject
whose aim is "To help the student, the general
practitioner, and the specialist to find an answer to
the problems associated with rational irradiation in
the treatment of benign and malignant conditions
affecting human beings"; The chapter on physics
has been re-written and includes an account of
radioactive isotopes and the Paterson Parker system
of radium dosage. This latter system, widely used
in England, hardly affects the clinical section, where
radium dose is usually stated in mgm. hours and
in one instance (p. 513), is given as an admixture of
mgm. hours and r units. Again, tongue implants on
p. 321 do not follow the suggested distribution as
described in the text, whilst Fig. 143 shows an
arrangement of radium needles where there must
be a very high "hot spot" or "hot spots" with these
crossed needles. Following American practice, X-ray

dosage is expressed as r in air, but total doses are

often given as the portal values. This neglect of the
important tumour and tissue dose has, as its corollary, a lack of general information concerning tumour
lethal doses. Isodosimetry, modern practices in field
planning, and beam direction methods are similarly
neglected. There is a small error on p. 33 where the
cloud chamber is attributed to C. W. Wilson instead
of C. T. R. Wilson.
The author describes the many and varied clinical
conditions which, in his large experience, are benefited by irradiation. The value of the work would
be enhanced by critical discussion of the indications
for the various techniques in relation to other
therapeutic methods that are available. The student
reading the book is left to synthesise the information
given in the light of his own education, and his
clinical experience must be wide and varied if he is
to benefit from its assimilation.
The book is beautifully produced, with a wealth
of excellent photographs, and is an honest account
of what can be done with ordinary methods of
standard X-ray and radium equipment.

546

I. G. WILLIAMS.