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Article Details
Clinical Video
Volume 4, Issue 11 (November Issue)

Abdominal Pain after Jejunal Feeding Tube Placement: An Unexpected Twist

Enrique Lázaro-Fontanet1, Francesco Abboretti1,2, Styliani Archontaki3 and Styliani Mantziari1*

1Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Switzerland

2Department of Surgery, Etablissement Hospitalier du Nord Vaudois (eHnv), Switzerland

3Department of Radiology, Etablissement Hospitalier du Nord Vaudois (eHnv), Switzerland

*Corresponding author: Styliani Mantziari, Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Rue du Bugnon 46, CH-1011 Lausanne, Switzerland. E-mail: Styliani.mantziari@chuv.ch

Received: September 28, 2022; Accepted: October 07, 2022; Published: October 25, 2022

Citation: Lázaro-Fontanet E, Abboretti F, Archontaki S, Mantziari S. Abdominal Pain after Jejunal Feeding Tube Placement: An Unexpected Twist. Clin Image Case Rep J. 2022; 4(11): 272.

The following video is related to this article (Video 1).

Abstract

A 63 year-old man presented with a two-week diffuse and intermittent abdominal pain, associated to nausea, biliary vomiting and impossibility of feeding. The patient was previously known for an esophageal adenocarcinoma treated by neoadjuvant chemotherapy and transhiatal oesophagectomy one year earlier. Severe malnutrition required a jejunostomy feeding tube placement according to the Witzel technique, which was removed several months later when oral diet sufficiently covered the patient’s caloric needs.

Physical examination revealed a diffusely tender abdomen without rebound. Biological inflammatory markers and venous lactate levels were within the normal range. An abdominal computed tomography (CT) was performed as shown in the video, revealing two complete twists of mesenteric vessels, known as “whirlpool sign” (Video, arrow), as well as an abrupt termination of a dilated intestinal segment (‘closed loop’ image). These radiological findings are highly suggestive of mesenteric volvulus.

An exploratory laparotomy was performed confirming the suspected diagnosis. During the surgical procedure, a thick adhesion was found between the jejunostomy loop and the abdominal wall, with no other remaining stitches (Image). This adhesion worked as a pivot, causing jejunal volvulus and occlusion. The jejunal loop was freed with no need for resection, and postoperative course was uneventful.

Midgut volvulus is an uncommon cause of mechanical intestinal obstruction in adults. In this case, the 3 previously placed ‘anti-twist’ stitches between the jejunal loop and the abdominal wall were no longer present, leaving only a one-point fibrous attachment which acted as a pivot for a complete twist (mesenteric rotation) of the loop as the jejunal tube was pulled upon during removal.