Past History. - The Physical Examination - Physical: Harry J - Cohen, and Paul J - Caivieron, New York, N. Y

GASTROESOPHAGEAL INTUSSUSCEPTION
HARRY J . COHEN, M.D., GEORGE WEISS, M.D., AND PAUL J . CAiVIERON, M.D.
NEW YORK, N. Y .
N T U S S U S C E P T I O N is the commonest cause of acute intestinal obstruction in

Ithechildren. I t is primarily a disease of infancy, 80 per cent of cases occurring in
first two years of life and 50 per cent between 5 and 7 months of age.
However, retrograde intussusception or invagination of the bowels from below
u p w a r d is a rarity. There are only scattered case reports in the literature, and
the diagnosis is usually made at operation or post mortem.
The following report is unique since not only was there a retrograde
intussusception but in addition the stomach, which is rarely involved, was the
site of the intussusception.
CASE REPORT
G. W., a 16-month-old Negro child, was admitted to H a r l e m Hospital on

Dee. 8, 1946, with a history of waking during the nigtlt gagging and vomiting
bright red blood. F o r supper the child had mashed potatoes and milk. A~ f a r
as the mother knew no foreign bodies, medications, or corrosives were accessible
to the child.
Past History.--The child had no previous serious illnesses. H e had had a
circumcision two weeks previous which was uneventful.
Physical Examination--Physical examination revealed a well-developed
and well-nourished male child who appeared somewhat sleepy and who was very
comfortable except for intervals when he vomited copious amounts of mucus
mixed-with bright red blood. There were no bleeding points seen in the nose,
mouth, or pharynx. The abdomen was soft, no masses were felt, and no tender-
ness was elicited, spleed and liver "were not enlarged, and x-ray of the stomach
and esophagus revealed no evidence o2 foreign body. Lungs were reported as
negative.
Laboratory Data.--Red blood cells were 4.23 millions; hemoglobin 13.9 Gin.;
white blood cells, 9,600 wit~:89 per cent polymorphonuclcars, 3 per cent stabs,
one per cent eosinophile; sickling p~eparation, negative; hematoerit, 52.2 per
cent; specific gravity of blood 1.064. Temperature varied between 98 and 99.2 ~
F. Pulse was 108 to 112, respirations, 24. To maintain water and electrolyte
balances continuous clyses were given.
The child remained comfortable throughout the first and part of the
second hospital day. Vomiting of bright red blood ceased after the first day
and the only evidence of hemorrhage was a few small, dark brown spots seen
about the bed sheet. Despite the infrequent vomiting on the second hospital
day and the administration of continuous clysis, dehydration became quite
pronounced. Toward the end of the second hospital day the child suddenly
developed acute respiratory distress and expired within t h i r t y minutes after
this acute episode.
An autopsy was performed.
Gross Pathological Dialgnosis.--Diagnosis was: (1) Intussusception of
a n t r u m of stomach into midesophagus with gangrene of intussusception and
high intestinal obstruction; (2) acute passive congestion of ]ungs., liver, and
~'rom the Pediatric Service (Morris Gleich, M.D., Director) and the Pathology Service
(Dr. Solomon Weintraub, Pathologist) of Harlem Hospital.
367
368 THE J O U R N A L OF P E D I A T R I C S
splanchnic bed; (3) dehydration; (4) moderate fatty change of liver; (5)
marked mesenteric lymphadenopathy. In the posterior mediastinum the esoph-
agus at its midpoint is seen to balloon out suddenly to 2.75 era. in diameter
from the usual 1.25 era. Palpation reveals it to be slightly boggy and firm. The
dilatation continues to the stomach. The esophageal hiatus is free of defects and
is bound in its usual tight manner to the wall of the esophagus. The stomach is
invaginated by its central portion which apparently has traversed the stomach
Fig. 1.--Ar~terior view. a, G r e a t e r c u r v a t u r e of s t o m a c h , b, K n u c k l e of s t o m a c h , c, L i v e r .

d, E s o p h a g u s w i t h i n t u s s u s c e p t i o n .
F i g . 2 . - - A n t e r i o r v i e w a f t e r o p e n i n g of e s o p h a g u s , a, L i v e r . b, E s o p h a g u s . c, I n t u s s u s c e p -
t u m . d, G r e a t e r c u r v a t u r e of s t o m ' a c h .
COHEN ET AL. : GA.STROESOPHAGEAL INTUSSUSCEPTION 369
and now rests in the esophagus in an extensive intussusception. The first portion
of the duodenum is slightly redundant, the remaining portions normal. The
remaining bowel does not a p p e a r unusual.
The stomach presents the picture of m a r k e d intussusception of the a n t r u m
into and as f a r as the midesophagus. There is as a result a knuckle of stomach
which extends about the intussusception f r o m anterior to posterior aspects of
the body of the stomach. The cardia, fundus, and greater curvature of the
stomach are not involved in the intussusception. The lesser c u r v a t u r e and
adjacent stomach and the lower half of the esophagus act as the intussusceptions.
The py]orus is drawn up somewhat by the intussusception f r o m its usual level
at the first l u m b a r segment. There is no d i a p h r a g m a t i c herniation o t h e r than
the intussusception. The duodenum is in its normal anatomical position except
for slight u p w a r d movement of t h e first portion with the pylorus. The gastro-
colic, gastrohepatic, a n d ' g a s t r o s p l e n i c ligaments are all without defect.
F i g . 3 . - - A f t e r d i s s e c t i o n of e s o p h a g u s , s t o m a c h , a n d p y l o r u s , a, E s o p h a g u s . b, A n t r u m
of s t o m a c h , c, P y l o r u s . d, A r e a i n t u s s u s c e p t e d ( h e m o r r h a g i c ) . e, E s o p h a g u s w i t h r e d a r e a
(where intussusccptum rested).
COMMENT
The normal difference in diameters between the small and large bowel
and the course of peristaltic waves f r o m above downward f a v o r isoperistaltic
intussusception. Occasionally, however, some local condition such as a t u m o r
mass, Meckel's diverticulum, edema at the site of a gastrojejunostomy, a gas-
tric diverticulum, chemical irritation, or even great abdominal distention m a y
so alter conditions as to cause reverse peristalsis and make lumen of the small
intestine relatively larger t h a n t h a t of the large bowel, thus producing a
r e t r o g r a d e type of intussusception.
The case reported is unusual inasmuch as the stomach was the site of the
intussusception and no visible pathogenetic factors were found to account for
the development of a retrograde t y p e of intussusception. The stomach is in-
volved in an intussusception rarely, as a review of the literature indicates
370 THE JOURNAL OF I~EDIATRICS
1, 2, 4-9. The stomach is invaginated less often than the intestine because (a)
it is well fixed at both curvatures, (b) its lumen decreases in the direction of
the peristaltic movement, and (e) there are no wandering rings of con-
traction as in the intestines. The reported eases of intussusception of the
stomach revealed predisposing etiologic factors in the majority of instances.
Desternes and Baudon ~ f o u n d marked gaseous distention of the abdomen to
have produced invagination of the stomach in their case. A t operation a per-
foration of the stomach with adhesions to the ]iver was found. Cure followed
surgical intervention. A polyp of the stomach was found by x-ray to be the
cause of invagination in some of the reported eases, ~, G, s and found on post
mortem in another instance. 2 A diverticulum of the greater curvature was
the point of origin of a gastroesophageal invagination as reported by IAaras
and Rieard. ~ The stoma of a gastrojejunostomy was the site at which an
inversion of the stomach occurred in another ease report." Experimentally i t
has been shown that the application of a mixture of .01 per cent silver nitrate
plus 15 per cent sodium nitrate to the a n t r m n of a dog's stomach caused edema
of the area irritated and a retrograde gastrogastrie intussusception resulted.
L a n n o n and Culiner ~ reported the case of a 3- to 4-year-old child with a history of
hematemesis and one that simulates our own ease in almost every respect. On
post mortem they found a retrograde intussusception of the lesser curvature,
pylgrus, and first p a r t of the duodenum into the esophagus.
SUMMARY
This is a report of a case of retrograde intussusception ill a 16-month-o]d
male infant in whom the pylorie end of the stomach was invaginated into the
esophagus. The outstanding symptom was hematemesis. Despite the decrease
in vomiting and the use of parenteral fluids, there was a continuous downhill
course associated with an unrelieved high intestinal obstruction. At post
mortem no etiologic factors were found which could have induced the develop-
ment of this type of intussusception. The literature on cases of retrograde
intussusception involving the stomach is reviewed and this ease is an' addition
to the few eases reported.
REFERENCES
1. Desternes and Bandon: Inversion totale de ]'estoraae par distension gazeuse de l'intestin,
Arch. d'61eetrie, m6d. 20: 291, 1912.
2. Fabrieius-3loller, J.: Invaginatio Ventrieule, tIosp.-Tid. 11: 1592, 1918.
3. Oselladore, G.: ExperlmentM Production of t~etrograde Gastro-gastrie Inva.gin~tion, Arch.
ital. d. raM. d. app. diger. 6: 401, 1937.
4. Lannon, J., and Culiner, A.: l~etrograde Intussusception of Lesser Curvature of Stomach,
Pylorus and P i r s t P a r t of Duodenum Into Esophagus, Brit. J. Surg. 33: 392, 1946.
5. Dohn, K., and Faber, B. : Invag'inatio~ of Stomach; Case Diagnosed by Means of Roentgen
Examination, Aeta radiol. 26: 56~ 1965.
6. Zdansky, E.: Invagination of Stomach; Report on One Case of Gastro-duodenal stud Two
Cases of Retrograde Gastrogastrie rnvagi~ation, Rbntgenpraxis 11: 537, 1939.
7. Liaras and Rieard~ E.: Circumferential D i l a t a t i o n of M e d i a s t i n a l Esophagus Due to
P a r t i a I Gastro-esophageM I n v a g i n a t i o n ; Case, Ann. d ' a n a t , path. 11: 868, 1934.
8. Lbnnerblad, L.: Stomach Invagination; Two Cases, Aeta radiol. 1r 82, 1933.
9. Poliquin~ P. A.: Stomach J e j u n o g a s t r i e I n v a g i n a t i o n , Union m6d. du Canada 73: 18, 1944.

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GASTROESOPHAGEAL INTUSSUSCEPTION

N T U S S U S C E P T I O N is the commonest cause of acute intestinal obstruction in

G. W., a 16-month-old Negro child, was admitted to H a r l e m Hospital on

Fig. 1.--Ar~terior view. a, G r e a t e r c u r v a t u r e of s t o m a c h , b, K n u c k l e of s t o m a c h , c, L i v e r .

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