Postgrad Med J: first published as 10.1136/pgmj.30.342.200 on 1 April 1954. Downloaded from 2O0 REPORT OF A CASE OF THRICE OCCURRING RETROGRADE INTUSSUSCEPTION OF THE EFFERENT LOOP OF JEJUNUM THROUGH A GASTRO-ENTEROSTOMY STOMA WITH A THEORY AS TO THE AETIOLOGY By MORTIMER BURDMAN, F.R.C.S. Whittington Hospital In the past 35 years there have been over 40 modic, each attack being accompanied by retch- cases reported of retrograde intussusceptiqn of the ing. He was admitted to hospital five hours after efferent loop of the jejunum into the stomach the onset of acute symptoms. through a gastro-enterostomy stoma.. On examination the patient was seen to be a Although these cases have been recorded, there thin man with three vertical scars in the middle seems to be little in the way of explanation of the of his upper abdomen. There was divarication of mechanism of Some retrograde intussusception. the recti, due to atrophy of the musculatureby copyright. suggestions as to aetiology have been put forward resulting from his four previous operations. The by different authors, but these have not success- upper abdomen was tender and mildly guarded. fully stood up to the criticisms of the proposers The lower abdomen was soft, and not tender to themselves. palpation. No masses were palpable. Rectal An effort has been made to consider the prob- examination revealed no tenderness or other abnor- lem in the light of physiological principles in an mality. Temperature was normal, pulse rate 55 per attempt to understand the mechanism of retro- minute, of good quality. The tongue was coated grade intussusception. and moist. On abdominal auscultation some bowel sounds were heard. http://pmj.bmj.com/ Case Report A tentative diagnosis of threatened leak in an Patient: R. G. Male, aged 43 years. Admitted anastomatic ulcer was made. The patient was to the Whittington Hospital on April 26, 1949, treated conservatively by means of a Ryle's tube with a history of stomach trouble for over zo years. with hourly aspirations, intravenous drip, sedation Had had four previous ' gastric ' operations, dated and an hourly pulse chart recording. During the 1934, 1940, I946 and I947. Subsequent enquiry next five hours the pain continued spasmodically, revealed them to be: and at the last aspiration 5 oz. of pure blood 1934. Wedge excision, chronic gastric ulcer were withdrawn, although there had been no on September 27, 2021 by guest. Protected on lesser curvature. blood in the previous hourly specimens. Between I940. Posterior gastro-enterostomy. the acute attacks of pain it was noted that there 1946. Intussusception of jejunum into the was marked lessening in the epigastric tenderness stomach-reduced. and guarding. The pulse rate had not risen. The 1947. As above. diagnosis of jejunal intussusception into the Since his last operation, he had had more or less stomach was made. Operation was undertaken persistent pain in the epigastrium, relieved by at once. alkaline tablets. On the day of admission the patient, who was a night shift worker, was awakened at 2 p.m. with Operation Note acute upper abdominal pain, followed immedi- Upper midline abdominal incision performed ately by nausea and vomiting. The patient thought with excision of one of the previous scars. Mul- there was a trace of blood in the vomitus, but he tiple adhesions were found in all areas of the could not be certain of this. The pain was spas- upper abdomen. There was no free fluid or peri- Postgrad Med J: first published as 10.1136/pgmj.30.342.200 on 1 April 1954. Downloaded from Arizl I954 BURDMAN : Retrograde Ittussisceptibn of the Efferent Loop ofYejunum 20o tonitis. The adhesions were slowly divided until onset of contraction proportional to the stretch. the anatomy could be recognized and restored. Distending force (rapid filling from above) The stomach was large and full, and its posterior Tonus = wall had been anastomosed in retro-colic fashion to Final length of muscle the jejunium. On raising the transverse colon, A muscle of high tone or spasticity, or a large small intestine was found to be herniating through sudden distending force will result in a severe the mesocolon and filling the stomach. contraction with small final length of muscle. The stomach was gently squeezed at the cardia The proximal end of the efferent loop gets between both the operator's hands, and its con- enlarged particularly in the rapidly emptying tents gradually reduced through the efferent loop. stomach, develops a wider lumen and appears In this way the whole of the stomach was emptied. more relaxed than the more distal jejunum. If Theapex ofthe intussusception was at a point about in rapid emptying, the loop becomes suddenly 30 cm. away from the stoma. In attempting to filled, the tension, stretching and change in reduce the last fewr inches of oedematous gut in the pressure is greater in the narrowing distal part proximal portion of the efferent loop, the bowel than in the relaxed proximal part. This is so, ruptured and further reduction became impossible. not only because the bbwel is narrower and more The remaining intussusception was resected and readily'stretched, but because it has a large part an end-to-end anastomosis was carried out. The of the downward force or weight of the efferent distehded proximal portion of the efferent loop loop contents above it, as well as the lateral force was narrowed by several Lembert sutures in the exerted by the contents at its own level. This transverse axis of the bowel in order to prevent narrowing portion responds with the greatest recurrence. No attempt was made to anchori this degree of contractibility, and by its strong con- gut. In vi/ew of the marked adhesions in all ~iitSe, traction raises the presatire in the loop above it so partial gastrectomy was not considered advisable. that the segment immediately above it becomes There was no evidence of anastomatic ulcer and further distended. This segment then contracts, the stoma took three fingers, although this may again raising the pressure above, and the sumby copyright. have been the result of stretching. The distended total is an anti-peristaltic wave, arising at a point proximal efferent loop was about 6 cm. in diameter of critical maximum pressure change, which forces while the collapsed small bowel below was about sorhe of the contents back into the stomach and 2 cm. in diameter. The stomach was dilated and prevents too rapid emptying. the afferent loop was negligible in length. The V. E. Henderson showed by a series of bowel stoma was low on the posterior aspect of the mugcle stretch experiments that the bowel stomach about cm. to the responded to distension by contraction and by 3 cephelad pylorus. peristaltic waves. The more rapid the rise in The patient made atn uneventful recovery and the less the actual amount of pressure pressure http://pmj.bmj.com/ iwas discharged within three weeks. It is now required to provoke the peristalsis. Relaxed four years since his discharge, and he has had no bowel requirts very high pressture to produce a indigestion, nausea, or vomiting. Barium meal very small degree of peristalsis. The peristaltic shows nbfmal emptying, but not any undue dis- wave, he says, ariises at a point where the pressure tension of the efferent loop. One can only be changes are most effectivei, and this point may extremely guarded as to the possibility of recur- change its plosition, dependent upon changes in presSttfe produiced by previous waves. Histological report of the specimen was Anti-pferiitalsis is a normal feature of duodenal on September 27, 2021 by guest. Protected ' Hiemorrhage into the mucoka and sub-miucsa movemert. Too rapid filling with resulting rapid df the itltissuscepted jejutiuin. No evidence of rise in duodenal pressure (Thoinas, Crider and polyp or small bowel tuifiour.' Mogan), or perhaps the presence of some solid particles which have escaped the pyloric sphincter A Theoir ofRetrogiatade Itisuiisceptibn (Cannon and Kleine), are considered to be the Retrograde peristalsis is a physiological m/chan- cause of the frequent and well recognized anti- isifn of the alimentary canial. Its function is to peristaltic waves commencing in the second and prevent over-distension and undue hurry of the third part of the duodenum passing upwards alimentary contents at all levels from thi oeso- through the bulb, pylorus and even the pyloric pliagustb the large bowel. It occurs particularly antrum. Similarly, a rapidly filling and dis- at the physiological junctlohs, although it may tending efferent loop of a gastro-entetostomy occur at any point where sudden ilico-ordinated stoma somietimes shows well pronounced anti- localized increase of intra-lutnenal pressure de- peristaltic waves radiologically, although isograde velops. Distensioh of a iobp bf bowel causes peristalsis is the more usual picture. stretching of the smooth miiscle ih it With resulting if a particularly violent initial segmentary con- Postgrad Med J: first published as 10.1136/pgmj.30.342.200 on 1 April 1954. Downloaded from 202 POSTGRADUATE MEDICAL JOURNAL April 1954 I I 2' 3 *1 1 'I16 'F'> 3 by copyright. I. Unusually severe contraction 2. Sudden increase of pressure 3. And drawing up of spastic of I, due to unstable bowel. at 2 causes momentary point I, which is then overstretching and tempor- caught by the recovery of ary paralysis with tem- point 2. porary dilation at 2 creating a momentary point of rela- tively lower pressure at A. traction occurred, perhaps associated with irritable the proximal loop, spreading over to the stomach, and spastic gut as suggested by the patient's excites at first ordinary peristalsis in these partshttp://pmj.bmj.com/ history of indigestion, then several phenomena with increased downward pressure to reduce spon- may occur co-incidentally: taneously the vast majority of what are probably (a) The initially contracting local segment may not rare transient intussusceptions.