Jejuno-jejunal intussusception following feeding jejunostomy: A case report and literature review

Abstract

Introduction

Feeding jejunostomy is a rare cause of jejuno-jejunal intussusception, with presentations ranging from mild bowel obstruction to severe ischemia or perforation.

Case presentation

A 21-year-old male with a recent history of feeding jejunostomy placement presented with acute upper abdominal pain, bilious vomiting, and inability to pass stool or flatus. Ultrasonography confirmed jejuno-jejunal intussusception, necessitating resection of the affected segment and jejuno-jejunal anastomosis. One year postoperatively, the patient remains asymptomatic with no recurrence.

Discussion

Review of 17 cases of jejuno-jejunal intussusception post-jejunostomy revealed abdominal pain, vomiting, and abdominal distension as common symptoms. Diagnosis relied on imaging modalities like ultrasound or CT, and surgery was the primary treatment.

Conclusion

This case underscores the importance of suspicion and timely intervention to prevent complications in patients with feeding jejunostomy presenting with obstructive symptoms.

Highlights

• •Jejuno-jejunal intussusception is a rare complication following feeding jejunostomy.
• •Surgical intervention, including resection and anastomosis, led to a favourable outcome and recovery.
• •Intussusception can occur at varying times post-surgery, with a median onset of 3 weeks.

1. Introduction

Feeding jejunostomy is frequently employed as a nutritional support measure when oral or gastric feeding is contraindicated [1]. Jejuno-jejunal intussusception is a rare complication of feeding jejunostomy [1]. The incidence of intussusception in adult is less than 1 % of all cases with feeding jejunostomy leading to jejuno-jejunal intussusception being particularly rare [2]. Jejuno-jejunal intussusception specifically involves one segment of the jejunum telescoping into another. Symptoms include nausea, vomiting, abdominal pain, and occasionally a palpable mass in the abdomen. These symptoms can often overlap with other gastrointestinal disorders, making intussusception a challenging diagnosis to confirm without imaging studies.

In adults, intussusception most frequently occurs in the small bowel (52 %), followed by the ileocecal region (38 %) [3]. Although feeding tube itself can act as lead point, the 90 % of adult jejuno-jejunal intussusceptions are linked to pathological lead points, such as adhesions or scarring from previous abdominal surgeries, benign and malignant lesions [4,5]. Ultrasound is preferred in emergencies for detecting intussusception with signs like the “target” or “doughnut” sign, but CT scan is the gold standard for detailed diagnosis, lead point identification, and assessing complications [6].

Management of jejuno-jejunal intussusception in adults post-feeding jejunostomy involves conservative approaches for mild cases and surgery for severe symptoms, complications, or failure of conservative treatment [7] [1].Following the SCARE 2023 guidelines, we present a rare clinical case of jejuno-jejunal intussusception following feeding jejunostomy [8].

2. Case presentation

A 21-year-old male, BMI 18.5 kg/m² presented with upper abdominal pain for three days associated with multiple episodes of bilious vomiting containing food particles and an inability to pass stool and flatus. He had undergone tracheoesophageal fistula repair (type E) with a feeding jejunostomy performed two months earlier at our center. The feeding jejunostomy was performed due to persistent feeding intolerance following the TEF repair. He had no similar episodes in the past, history of hypertension, pulmonary tuberculosis, or diabetes mellitus.

On examination, his vital signs were stable. Physical examination revealed a soft, distended abdomen with tenderness over the left hypogastrium without guarding or rigidity. His feeding jejunostomy was intact. Percussion of the abdomen revealed a tympanic note.

Laboratory investigations, including complete blood count, liver function tests, and renal function tests, were all within normal limits. An abdominal and pelvic ultrasound (USG) identified a 6.2 cm segment of jejunal intussusception located beneath the feeding jejunostomy site. The intussusception displayed a characteristic “target” appearance on cross-sectional imaging (Fig. 1).

Fig. 1.

USG showing multiple concentric hyperechoic and hypoechoic rings.

Doppler assessment confirmed the presence of color flow within the bowel wall.

He was kept Nil Per Os and started on intravenous fluids, analgesics, and antiemetics. He was subsequently taken for an exploratory laparotomy. Intraoperatively, a jejunal intussusception was identified approximately 10 cm distal to the duodenojejunal flexure, with collapsed distal segment (Fig. 2).

Fig. 2.

Intraoperative findings showing jejunal intussusception.

Approximately 30 mL of turbid fluid was noted in the left paracolic gutter and left iliac fossa, along with dense adhesions. Although the jejunum appeared grossly normal, the segment was resected due to non-viable areas and the risk of recurrence. A jejuno-jejunal anastomosis was performed, and the feeding jejunostomy was removed. The jejunostomy had been placed using a 12 Fr balloon catheter, with the balloon inflated using 5 mL of sterile water.

The patient's postoperative course was uneventful and he was started on oral feeds on second postoperative day. Histopathological examination of the resected tissue revealed normal bowel mucosa with reactive changes and no evidence of malignancy or other significant pathology. At one year follow-up, he remained asymptomatic, with no recurrence of symptoms.

3. Discussion

Jejuno-jejunal intussusception following feeding jejunostomy is a rare condition that adds complexity to diagnosis and treatment. We conducted a literature search in PUBMED (until August 9, 2024) for cases of intussusception following feeding jejunostomy, which yielded 15 studies published between 1998 and 2024. After excluding 1 article due to unavailability, 14 studies reporting 17 cases were analyzed. (Table 1).

Table 1.

Patients' clinical characteristics.

S.N.		Author, year	Country	Age (in year) /Sex	Indication for feeding jejunostomy	Symptoms	JJI after FJ (duration in weeks)	Diagnosis made via	Treatment (conservative/surgrey)	Distance of intussusception from FJ insertion
1		T.K. Nulukurthi et.al [9] 2023	India	76/F	CA Esophagus	AP, Obstipation	8	CECT	Laparotomy & Reduction	20 cm distal
2		S. Dutta et.al [1] 2021	India	54/M	CA Stomach	AP, AD, V	1	USG Abdomen, CECT	Laparotomy & Reduction	20 cm
3		H Sakthivel et.al [10] 2018	India	48/NA	SCC Esophagus	AP, AD	1	CECT	Reduction	NA
				57/M	CA Esophagus	AP, AD	1	USG Abdomen, CECT	Reduction	10 cm distal
				24/F	Deformed pylorus due to chronic PUD	AP, V	1	Exploratory Laparotomy	Reduction	NA
				29/M	Esophageal ulceration	AP, V	4	USG Abdomen, CECT	Conservative management	At the site of FJ
4		S. Dholaria et.al [5] 2017	India	35/F	CA esophagus	AP, V	1	X-ray Abdomen, USG Abdomen	Surgical reduction	At the site of FJ
5		S. Krishna et.al [11] 2013	India	33/M	CA cricopharynx	AP, V	4	USG Abdomen, CT Abdomen	Resection with jejuno-jejunal anastomosis.	5 cm distal
6		P. kohli et.al [12] 2021	India	25/F	CA esophagus	V, Leakage from FJ site	4	CECT	Surgical resection and end-to-end anastomosis	NA
7		S.Mahalingam et.al [13] 2013	India	59/F	CA stomach	IO	6	Gastrograffin study	Reduction & releasing the adhesions.	distal
8		J. Tian et.al [2] 2022	USA	70/M	Dislodged PEG	FJ tube obstruction	3	CT Abdomen	Laparotomy & resection	At the site of FJ
9		A. Chirihan et.al [14] 2022	Morocco	44/M	DYSPHAGIA due to caustic ingestion	AP, AD, V	1	CECT	Reduction	35 cm proximal
10		N.R. Dash et.al [15] 2018	India	28/F	Esophageal stricture	AP, IO	104	Clinical, Intraoperative	Resection and exteriorization	NA
11		T.S. Kareem et.al [16] 2020	Iraq	63/F	Gastric outlet obstruction	AP, V, indigestion	3	CECT	Reduction & Resection with end to end anastomosis	At the site of FJ
12		S. Chawla et.al [17] 2021	India	18/F	Esophageal stricture & pyloric stenosis	AP	4	USG abdomen, CECT	Reduction	NA
13		S.S. Lee et.al [18] 2024	Republic of Korea	19/F	Traumatic brain injury	V, Fever	8	X-ray Abdomen, CECT, Endoscopy	Resections with end to-end anastomoses	NA
14		P.J. Testart [19] 1998	NA	46/M	CA Esophagus	AP, V	2	X-ray abdomen, intraoperative	Manual reduction	At the site of FJ

Abbreviations: CA: Carcinoma; SCC: Squamous Cell Carcinoma; PEG: Percutaneous Endoscopic Gastrectomy; FJ: Feeding Tube; AP: Abdominal Pain; AD: Abdominal Distension; V: Vomiting; IO: Intestinal Obstruction; JI: Jejunal Intussusception

The mean age of patients was 42.83 years (range: 18–76 years), and 41.17 % were male. Most reports were case studies, with 2 being case series. The most common presenting symptoms were abdominal pain (76.47 %), vomiting (58.82 %), and abdominal distension (23.52 %). The median time to intussusception onset was 3 weeks post-feeding tube placement, ranging from 1 week to 2 years. Two cases involved balloon catheters acting as the lead point for intussusception, indicating iatrogenic causes in certain instances. In 10 of these cases, the feeding jejunostomy tube was reinserted after treatment.

Different theories have been proposed to explain intussusception secondary to the placement of feeding tubes [20] [21]. The tip of the feeding tube may act as a leading point, allowing the proximal segment of the bowel to slide over the distal segment during peristalsis. The mechanical forces from feeding pumps, especially with larger or longer tubes, may also precipitate intussusception. Additionally, factors like retrograde peristalsis during vomiting or reduced mesenteric fat (common in poorly nourished patients) can contribute. [13,21]. In our case, the dense adhesions could have contributed to the development of intussusception by creating fixation points and abnormal bowel motility.

Our patient presented with typical signs of bowel obstruction, including upper abdominal pain, bilious vomiting, and inability to pass stool and flatus, which are consistent with symptoms reported in the literature. Physical examination in our case revealed a soft, distended abdomen with localized tenderness, but without guarding or rigidity, aligning with typical findings described in the literature. While 30 % of intussusception cases occur within 30 days of tube insertion, our case presented two months later, demonstrating the variable time for onset. [22].

Ultrasound (USG) and computed tomography (CT) are crucial for diagnosing intussusception. [23]. The USG in our case revealed a characteristic “target” appearance, a hallmark feature of intussusception. Although CT is often the preferred modality for adult patients, especially for its ability to detect mesenteric vessels and fat within the intussuscepted bowel, it was not performed due to institutional protocol and economic constraints. [24].

Treatment for jejuno-jejunal intussusception in adults depends on the severity of symptoms and underlying pathology. Management options include changing the tube to a standard or short tube without a distal pigtail, reducing the intussusception by injecting air or contrast through the tube, or exchanging the tube over a guidewire under fluoroscopic guidance [20]. However, these measures are effective only in cases with transient radiological evidence of intussusception. While non-surgical options like hydrostatic reduction have been attempted, they are generally unsuccessful in adults with bowel ischemia or obstruction [25] [26]. In such cases, surgical intervention, including resection of the involved bowel segment, is required. [27]. Resection is recommended in cases of stenosis, perforation, or gangrene. After surgery, the feeding tube can be used without a significant risk of intussusception recurrence [28].

The mainstay of treatment for jejuno-jejunal intussusception is surgery, particularly in cases where it results in bowel obstruction or other severe complications [29].

In our case, resection of the intussuscepted segment and subsequent jejuno-jejunal anastomosis were performed, along with the removal of the feeding jejunostomy. This approach aligns with the management strategies reported in the literature, where timely surgical intervention is emphasized to prevent further complications and ensure favourable outcomes.

4. Conclusion

Our case underscores the importance of maintaining a high index of suspicion for jejuno-jejunal intussusception in patients with feeding jejunostomy presenting with obstructive symptoms. Early diagnosis through imaging and timely surgical management prevents severe complications and recurrence.

Consent

Written informed consent was obtained from the patient's parents for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Since this is a case report and review of literature, our Institutional board has waived the requirement for ethical approval.

Funding

This study received no funding.

Author's contribution

S.P., P.L. formulated the original manuscript. S.P., P.L., S.P., A.S., B.G. and S.P. reviewed and edited the manuscript. B.G., S.P. and P.L. supervised the case. All the authors reviewed and approved the final version of the manuscript.

Guarantor

Prajjwol Luitel.

Research registration number

1.Name of the registry: None.

2.Unique identifying number or registration ID: None.

3.Hyperlink to your specific registration (must be publicly accessible and will be checked): None.

Declaration of Generative AI and AI-assisted technologies in the writing

Chat GPT 4 was used to improve readability and language; however, we assure that the authors are ultimately responsible for and accountable for the contents of the work.

Declaration of competing interest

No conflicts of interest were identified in the preparation of this case report and review of literature.

Data availability

The datasets used during this study will be available from the corresponding author upon reasonable request.