A 31-year-old woman presented with an acute onset of epigastric abdominal pain accompanied with nausea and vomiting. The pain had awoken her from her sleep. She denied fever or chills, had passed a bowel movement in the previous 24 hours, and had not sustained trauma. The past medical history revealed a Roux-en-Y gastric bypass operation for weight reduction approximately three years ago, followed by weight loss. On physical examination, there was a significant amount of tenderness appreciated in the epigastric region with minimal radiation. Laboratory tests, including a battery of electrolytes, liver function tests, and a complete blood count, revealed only mild hypokalemia (3.3 meq/L (normal range 3.5-5.3 meq/L)). Her white blood cell count was normal. An abdominal radiograph (Figure 1) and a CT scan (Figure 2) were obtained.
The abdominal radiograph (Figure 1) revealed marked dilated loops of bowel with scattered air-fluid levels that heightened the suspicion of an impending bowel obstruction. A CT scan (Figure 2) of the abdomen and pelvis with oral contrast and intravenous was obtained. CT showed marked dilatated stomach, duodenum and proximal jejunum, with non-dilated distal jejunum, ileum, and colon; these findings were indicative of proximal small bowel obstruction. In addition, there were "target lesions" identified in the left lower abdomen diagnostic of intussusception. The decision was made to take the patient to the operating room.
An exploratory laparotomy was performed and upon entering the peritoneal cavity a large 'football' shaped mass was found. There was a large amount of intussuscepted small bowel that had telescoped into the confluence point of the Roux-en-Y anastomosis. The intussusception was retrograde with the efferent limb constituting the intussusceptum. The efferent limb was successfully reduced from the intussuscipiens, which was the anastamotic site between the Roux limb and the afferent limb. The intussusceptum consisted of three feet of jejunum and was deemed viable. A decision was made to revise the Roux-en-Y anastomosis to eliminate any future bouts of intussusception from that particular lead point. The patient recovered uneventfully.