A near-fatal case of intussusception and ischaemic perforation of stomach in first-trimester pregnancy: eight years after laparoscopic Roux-en-Y gastric bypass

Abstract

The increasing demand and popularity of bariatric surgery are not only due to the ever-increasing obesity epidemic but to tackle obesity-related comorbidities like diabetes and hypertension. However, bariatric surgery is not free of complications. One rare complication is intussusception, jejuno-jejunal intussusception being the most common. Intussusception has been defined both in pregnant and in non-pregnant women as well as men. We describe the case of a 40-year-old woman in the first trimester of pregnancy came to the hospital with worsening abdominal pain, was found to have intussusception of small bowel involving the jejunum, along with ischaemic perforation and necrosis of the fundus of the stomach. Postsurgery, the patient had a complete recovery and eventually, she successfully delivered an intact, viable fetus.

Background

In the present scenario where obesity is an epidemic, bariatric surgery is fast becoming a viable option for many. Occurrences of intussusception, an otherwise rare but fatal complication, are therefore bound to increase. The aetiology of postbariatric intussusception, however, is largely unknown. Diagnosis necessitates a high index of clinical suspicion and appropriate imaging studies. There should be a very low threshold for surgical exploration even if the diagnosis is equivocal.

Case presentation

A 40-year-old Caucasian woman in the first trimester of pregnancy came to the hospital with worsening abdominal pain, 10/10 in intensity and tearing in character. The pain was more localised in her epigastric and periumbilical region and was associated with nausea and vomiting frank blood. Her symptoms started on the morning of the same day she presented with feeling nauseous and vomiting non-bloody gastric content. She developed crampy abdominal pain that progressively worsened throughout the day and started vomiting blood actively in the evening. Her significant medical history included Rh incompatibility and bariatric surgery in 2009 (laparoscopic gastric bypass with Roux-en-Y anastomosis).

The nasogastric tube was placed, and ultrasound of abdomen done in the local hospital showed 9.6 cm lobulated mostly solid mass versus an abnormal segment of bowel located in the left lower quadrant. Abdominal MRI done at the same hospital showed intussusception of small bowel involving the jejunum with obstruction and dilated small bowel loops up to 5 cm diameter along the duodenal sweep and proximal jejunum (figure 1). There was marked abdominal distension, with guarding and rebound tenderness and hypoactive bowel sounds. Laboratory results were remarkable for neutrophilic leucocytosis and haemoglobin of 12.7 g/dL. Intravenous fluids were administered, and two units of packed red blood cells (PRBCs) were kept on hold. The patient’s abdominal pain was severe and uncontrolled even by maximum permissible doses of hydromorphone.

Figure 1.

An MRI of abdomen of the patient with intussusception. Telescopic sign is seen on the coronal views, (A) and (C). Target sign is seen on both axial and sagittal views, (D) and (B) respectively.

Intravenous pantoprazole and ondansetron were started. Immediate exploratory laparotomy was performed. On entering the peritoneal cavity, there was a gush of bilious fluid. About 2 L of bilious fluid was suctioned. There was jejuno-jejunal intussusception with extensive ischaemic necrosis of the jejunostomy site. The Roux site proximal to the jejuno-jejunal intussusception site was divided. The markedly distended biliopancreatic limb proximal to the jejuno-jejunal intussusception, and the small bowel distal to the intussusception was split using a GIA stapler. Thus step-by-step, the ischaemic intussusception site was carefully resected out and sent for pathological examination. Continued exploration of the stomach to evaluate the source of the bilious drainage revealed ischaemic perforation and necrosis of the proximal fundus of the bypassed stomach. It was partially resected out and later revealed pathological findings of acute focal inflammation with transmural necrosis. The Roux limb along with the gastric pouch was viable and intact. There were microscopic serosal tears which were sutured. The biliopancreatic limb excepting the perforated proximal stomach was viable and intact. The necrotic fundus of the stomach was resected after carefully dissecting the short gastric vessels. Gastrointestinal continuity was established after anastomosing the divided end of the Roux limb with the distal small bowel. Next step was to anastomose the resected end of the biliopancreatic limb to this newly apposed segment of bowel. This was done 60 cm proximal to the anastomosis (between the Roux limb and the distal segment of the bowel). The whole bowel segments were re-examined, and bleeding vessels were cauterised. Thorough irrigation of the peritoneal cavity was performed.

Postsurgery, the patient got transferred to the surgical intensive care unit on mechanical ventilation, started on meropenem, and once she became stable, she was extubated. She was then transferred to a centre with a high-risk neonatal unit for management of her overall condition including her pregnancy. She made a complete recovery with an intact, viable fetus.

Investigations

X-ray abdomen, MRI abdomen, Ultrasound abdomen.

Differential diagnosis

Intestinal obstruction, anastomotic ulcers, oesophageal ulcerations, GI perforation.

Treatment

Resection and anastomosis with perforation repair.

Outcome and follow-up

Successful continuation of pregnancy following complete recovery.

Discussion

Over the period of years, laparoscopic Roux-en-Y gastric bypass (LRYGB) has evolved as the premier surgical option to treat morbid obesity, which is an epidemic in the developed countries. Bowel occlusion post Roux-en-Y gastric bypass (RYGB) usually occurs as fibrous membranes, internal hernia or intussusception. Cases of postoperative intussusception in RYGB have been reported previously in literature.^{1 2} There is a case report of intussusception after 7 years postbariatric surgery.² Only a few cases of acute small bowel obstruction in an RYGB complicating pregnancy has been described in medical literature.^{3 4} The aetiology of postbariatric intussusception, is mostly unknown. An iatrogenic lead point created by the suture or staple line at the enteroenteral anastomosis may generate hyperperistalsis of the excluded segment causing the biliopancreatic limb to telescope into the common limb.^5–8 To say for sure, whether pregnancy can increase the risk for the intussusception is difficult, a marked reduction in the weight can generate an attenuated thin mesentery that is prone to twisting or intussusception.

At least half of the patients undergoing weight loss surgery are women of childbearing age.⁹ Postsurgical weight reduction in the obese patient results in improvement in fertility.¹⁰

Nausea and hyperemesis that generally occur during pregnancy can mask the development of an small bowel obstruction; hence, threshold of suspicion to detect any complication should be low.

Post-LRYGB intussusception can be anterograde or retrograde. Retrograde intussusception is the more common mode of intussusception, in the pregnant^11–14 as well as the non-pregnant.¹⁵

While reduction of the intussusception alone is safe and effective, there is a significant risk of recurrence. Resection, and end-to-end anastomosis, of the J-J point seems an effective means of treatment. The diagnostic modality of choice is the CT scan of the abdomen, but even a low dose CT scan inarguably carries risk of fetal affection.¹³ In our case, the modality used was MRI. Important to note that any delay in timely intervention can increase fetomaternal mortality to a large extent. Surgery within 48 hours has 10% mortality whereas, after 48 hours, it is 50%.¹⁶ One neonatal death due to necrotising enterocolitis has been reported.¹¹

Learning points.

• Early recognition and low threshold for suspicion of this complication, as this might be fatal.

• To create awareness among bariatric surgeons and the medical community in particular about the prevalence of intussusception, diagnosis and management of intussusception.

• Details of managing a pregnant patient with this complication will strengthen the existing experience and enable create guidelines in the future.