duodeno - duodenal intussusception , which involves the distal invagination of a segment of the duodenum , is a rare condition owing to the retroperitoneal fixation of the duodenum , which is sometime absent in cases of intestinal malrotation .
the vast majority ( 8090% ) of cases of intestinal intussusception are secondary to pathological masses in the intestine , such as brunner s gland hamartomas , lipomas and adenomas .
the presence of a duodenal membrane may cause retention of food resembling a pathologic mass , which may in turn facilitate intussusception .
we describe the interesting case of a patient with intestinal malrotation who developed acute pancreatitis as a result of a duodenal intussusception involving the head of pancreas which was caused by a duodenal membrane .
other symptoms include gastro - oesophageal reflux , weight loss , fatigue , anaemia due to iron deficiency ; pancreatitis due to obstruction of the outlet duct has also been described [ 36 ] . owing to the intermittent nature of the symptoms delay in diagnosis
symptoms had started three days previously and consisted of intermittent peri - umbilical pain , nausea and vomiting .
the initial physical examination indicated a healthy young man with mild epigastric tenderness . in infancy
he had undergone surgery for a congenital heart malformation involving closure of atrial and ventricular septal defects . during childhood
he had been treated with proton - pump inhibitors for symptoms of gastro - oesophageal reflux , and he had a history of intermittent post - prandial abdominal pain , but had never undergone endoscopic examination , or any abdominal surgery . presented with a normal height and weight for his age with a body mass index of 25 .
routine blood analyses revealed elevated levels of s - amylase ( 408 u / l ; ref .
subsequently the patient developed fever , ( core body temperature 38.6  c ) ; acute cholecystitis was suspected so he was treated with intravenous antibiotics .
subsequent abdominal ultrasonography was inconclusive , although there were signs consistent with a tumour in the head of the pancreas .
a ct - scan revealed a duodeno - duodenal intussusception involving the head of the pancreas and the common bile duct ( figs . 1 and 2 ) .
these finding were confirmed at laparotomy and non - rotation of the duodenum was also noted ( fig .
the intussusception was released , and a duodenotomy revealed a duodenal membrane with a narrow central opening ( fig .
s - bilirubin and s - amylase levels were within the normal range at discharge .
to our knowledge this is the first case report of pancreatitis resulting from duodenal invagination caused by a duodenal membrane .
high peristaltic pressure proximal to the stenosis may have contributed to the development of the invagination , which may also have been facilitated by the mobile , non - rotated duodenum , which had a vertical straight course without retroperitoneal fixation .
cases in which an intraluminal polypoid mass or tumour in the duodenum resulted in duodeno - jejunal intussusception have been reported . in a few cases the intussusception involved the head of the pancreas , resulting in acute pancreatitis .
these patients were treated by surgical reduction of the intussusception and duodenal resection or polypectomy .
membranous duodenal stenosis is often treated by duodenotomy and excision of the membrane followed by a duodenoplasty , or by duodeno - jejunal anastomosis , with good results . in our case
the patient had persistent symptoms of gastro - oesophageal reflux , which should have triggered an upper gi endoscopy ; had this revealed the intestinal malformation the patient could have been treated in a timely fashion and which would have avoided this serious complication .
the intussusception was not detected by ultrasonography but was revealed by a ct - scan .
a previous study found that 27.1% of patients with intestinal malrotation had a history of congenital cardiovascular defects .
this suggests that all children with intermittent upper gastrointestinal symptoms such as vomiting , abdominal pain and gastro - oesophageal reflux , particularly those with a history of congenital heart malformation , should undergo upper gi endoscopy and imaging of the gi - tract to exclude gi anomalies .
written informed consent was obtained from the patient for publication of this case report and accompanying images .
a copy of the written consent is available for review by the editor - in - chief of this journal on request .
 highlightsintussusception is not always seen on ultrasonography but can revealed by a ct-scan.any child , and especially those with previous congenital disorders , must undergo upper gi- endoscopy at the presence of intermittent upper gastrointestinal symptoms as vomiting , abdominal pain and gastro - oesophageal reflux , to exclude upper gi anomaly . 
Introduction
Presentation of case
Discussion
Patient consent