Gastrogastric Intussusception in an Adult Patient Without a Pathological Lead Point: A Case Report

Abstract

Gastrogastric intussusception (GGI) is the rarest form of adult intussusception, frequently linked to an underlying pathological lead point. This report presents a case of GGI without a pathological lead point, possibly only the second such case in literature where a lead point was not present.

A 57-year-old male underwent a successful ileostomy reversal following a low anterior resection for rectal carcinoma. Postoperatively, the patient experienced an acute onset of retching, vomiting, and inability to tolerate oral intake on the fourth postoperative day. Nasogastric tube placement was attempted, which was met with resistance, preventing its successful placement into the stomach. A contrast-enhanced computed tomography scan of the abdomen was subsequently performed, revealing the presence of GGI. An attempt at endoscopic reduction was made but proved unsuccessful. Following this, surgical reduction with gastropexy was undertaken.

Keywords

gastrogastric intussusception - gastric volvulus - obstruction

Introduction

Intussusception refers to the invagination of one segment of the gastrointestinal (GI) tract into an adjacent segment.[1] Typically, this involves the telescoping of a proximal portion (intussusceptum) into a distal segment (intussuscipiens), constituting the more common antegrade form; retrograde intussusception is exceedingly rare.[2] While intussusception predominantly affects the pediatric population—accounting for over 90% of cases—it is relatively uncommon in adults, comprising less than 5% of all instances.[3]

Intussusception is commonly seen in small or large bowel. Gastrogastric intussusception (GGI), a subtype involving the stomach, is an extremely rare clinical entity.[3] [4] It occurs when one portion of the stomach invaginates into another region. This condition is usually associated with structural abnormalities such as neoplasms, postoperative anatomical changes, or adhesions. Idiopathic cases, particularly those without an identifiable lead point, are exceedingly rare. The majority of GGI cases have been described in individuals with a history of bariatric or gastric surgery. Given the potential for delayed recognition, especially in patients without obvious risk factors, heightened clinical vigilance is crucial to avoid complications.[5] [6]

In adults, the management of intussusception generally necessitates surgical intervention, contrasting with the pediatric population, where nonoperative reduction is often successful due to the frequent absence of an anatomical lead point. Here, we report an extremely rare case of GGI in an adult male without an identifiable lead point. To date, only one other similar case has been documented in the literature.[3]

Case Presentation

A 57-year-old male with a known history of hypothyroidism was admitted to the surgical gastroenterology unit in November 2022 for ileostomy reversal. He had previously undergone a low anterior resection with ileostomy in August 2022 for rectal carcinoma. The ileostomy reversal was completed successfully.

On the fourth postoperative day, the patient developed acute-onset retching, vomiting, poor appetite, and was unable to tolerate oral intake. A provisional diagnosis of paralytic ileus versus gastric volvulus was considered. An attempt to insert a nasogastric tube was made but was unsuccessful due to resistance, suggesting an obstruction.

Initially, the surgical team requested a computed tomography (CT) scan of the abdomen on the fourth postoperative day to rule out any adynamic obstruction or anastomotic leak. A noncontrast CT was performed first, which revealed a narrowing in the gastric body. Based on these findings, the attending radiologist made an on-the-spot decision to administer positive oral contrast to further evaluate the suspected abnormality. This was an immediate, on-table clinical decision made by the radiologist on duty. A contrast-enhanced computed tomography (CECT) scan of the abdomen and pelvis was performed. Positive oral contrast study using diluted iohexol mixed with water was administered on-table. The imaging revealed a distended fundus and proximal body of the stomach, whereas the distal body and antrum appeared collapsed, with a notable constriction at the mid-stomach. These findings raised suspicion of an underlying gastric pathology.

The administration of positive oral contrast confirmed a distended, contrast-filled fundus and proximal body, with a collapsed distal segment and no contrast passage beyond the point of constriction ([Fig. 1]). Careful examination revealed an invagination of the distal stomach into the proximal segment, consistent with GGI. No abnormal gastric wall enhancement, mass lesion, perigastric lymphadenopathy, fluid collection, or disruption of perigastric fat planes was noted. The gastric axis was preserved, and there were no imaging features to suggest volvulus. CT performed in delayed phase, approximately 1 hour after oral contrast administration, demonstrated contrast hold-up in the gastric fundus with no passage beyond the level of the GGI ([Fig. 2]). Schematic line diagrams in axial, coronal, and sagittal planes depict GGI and enhance the visual understanding of the case ([Fig. 3]). Based on these findings, a diagnosis of GGI was suspected. On endoscopy, the gastric orientation appeared normal; however, luminal narrowing was observed, with gastric mucosal folds that were thickened, crowded, and demonstrated bunching and telescoping. No polyp or mass was identified. These findings further supported the suspicion of GGI. An endoscopic reduction attempt was made but was unsuccessful. The patient was then taken for surgical intervention. Intraoperatively, the diagnosis of GGI was confirmed ([Fig. 4]). The intussusception was reduced, and the stomach was secured to the abdominal wall through a gastropexy.

Fig. 1 Contrast-enhanced CT of abdomen in portal phase with positive oral contrast in axial (A), coronal (B), and sagittal (C) planes showing gastrogastric intussusception (yellow star) with dilated and contrast-filled proximal stomach (blue arrows in A, B, C) and collapsed distal stomach. Note the failure of passage of contrast across the intussusception. Red arrow in A denotes colon. CT, computed tomography.

Fig. 2 Coronal (A) and sagittal (B) CT images obtained during the delayed phase, approximately one hour following oral contrast administration, demonstrate contrast retention within the proximal stomach. There is no evidence of contrast passage beyond the site of gastrogastric intussusception. The point of intussusception is indicated by red arrows. CT, computed tomography.

Fig. 3 Schematic line diagram of CT scan in axial (A), coronal (B), and sagittal (C) planes demonstrating gastrogastric intussusception. CT, computed tomography.

Fig. 4 Intraoperative photographs (A, B) showing gastrogastric intussusception (blue arrow in A).

The patient had an uneventful postoperative recovery and was discharged in stable condition. The patient was monitored for 1 year postoperatively, with no signs of recurrence observed.

Discussion

GGI is an exceptionally rare form of intussusception, with only 22 cases documented in the literature between 1950 and 2024. Among these, 21 cases were associated with a pathological lead point, whereas only one case lacked an identifiable cause. The present case represents just the second instance in which no lead point was found, further underscoring its rarity.

GGI primarily affects adults, with a mean age of presentation of 67 years based on reported cases. Notably, females were disproportionately affected, comprising 81.8% of cases (n = 18) compared with males (n = 4; 18.2%). The most commonly identified pathological lead point was a GI stromal tumor (n = 7), followed by gastric polyps (n = 5), leiomyomas (n = 3), adenocarcinomas (n = 2), and neuroendocrine tumors and lymphomas (n = 5).[3] [6] [7]

GGI typically presents with nonbilious vomiting, upper abdominal pain, nausea, retching, or melena. The duration of symptoms can vary widely, ranging from a few hours to several years. Clinically, gastric volvulus is often the most suspected diagnosis due to the overlapping presentation.[8]

Imaging plays a critical role in establishing the diagnosis and excluding other potential causes. CECT is the primary diagnostic modality, with reported accuracy ranging from 50 to 100%. CT typically demonstrates the invagination of one part of the stomach into another—most commonly, the proximal portion into the distal.[3] However, in our case, the reverse was observed, with the distal stomach invaginating into the proximal portion. Of the 22 reported cases of gastrogastric intussusception to date, the literature does not specify how many were retrograde versus anterograde. In our case, the intussusception was retrograde, with the distal portion of the stomach telescoping into the proximal portion, resulting in a constriction at the level of the gastric body.

The use of positive oral contrast, as employed in our case, can be particularly helpful in visualizing failure of contrast passage beyond the point of intussusception and in identifying a dilated proximal gastric lumen. Gastric volvulus, a key differential diagnosis, must be ruled out by assessing the gastric axis and the anatomical position of the gastroesophageal junction and pylorus.[3] Another important differential diagnosis of gastric outlet obstruction, which can mimic GGI, is hypertrophic pyloric stenosis (HPS). On CT imaging, HPS typically demonstrates a concentric, circumferential thickening of the gastric wall with luminal narrowing involving the pylorus. This is in contrast to GGI, which usually exhibits a characteristic “bowel-within-bowel” configuration, producing the target sign. Since GGI is frequently associated with a pathological lead point, a soft tissue mass may also be identified within the intussuscepted segment. On endoscopy, HPS appears as a narrowed, smooth-walled pyloric canal, often producing the so-called “cervix sign.” Advancing the endoscope through the narrowed lumen may be technically challenging. In contrast, endoscopic examination in GGI reveals luminal narrowing with thickened, edematous gastric folds that appear crowded, bunched, and telescoped. On ultrasonography, HPS demonstrates an elongated pyloric canal with marked thickening of the muscularis propria. By comparison, GGI typically shows the “target sign” or “pseudo-kidney sign” of a telescoping bowel loop, with the lead point occasionally visualized within the intussusception.

It is also essential to assess for potential lead points, such as tumors or polyps, and to evaluate the enhancement pattern of the gastric wall to determine viability and rule out ischemia. Depending on the clinical presentation and chronicity of symptoms, an upper GI series may also be considered. However, ultrasound has limited utility in diagnosing GGI due to its rarity and interference from bowel gas, which often obscures gastric anatomy.[9] [10]

The reported CT appearances of gastric intussusception can vary: some case reports present unequivocal radiologic images,[11] [12] while others[2] [13] [14]—similar to ours—have less classic radiologic appearance but are supported by endoscopic and/or surgical confirmation. In summary, while the radiologic appearance alone can sometimes be misleading, the combination of clinical presentation, persistent failure of contrast passage, endoscopic findings, and surgical confirmation in our patient makes the diagnosis of intussusception the most plausible and evidence-based conclusion.

The definitive treatment for GGI is surgical intervention. In selected cases, particularly when gastric ischemia has been ruled out by CT, endoscopic reduction may be initially attempted. However, laparoscopic reduction combined with gastropexyis increasingly favored due to its minimally invasive nature and associated faster recovery times.[3] Nonsurgical methods such as hydrostatic or pneumatic reduction, commonly used in the pediatric population, have not been applied in cases of GGI. This is largely due to the high incidence of underlying pathological causes, including a significant rate of malignancy. In cases involving benign gastric tumors, reduction of the intussusception followed by excision of the mass is typically sufficient. Conversely, when a malignant tumor is identified, en bloc resection is the preferred approach.[3] In our patient, manual reduction of the intussusception was performed, followed by gastropexy to prevent recurrence.

Conclusion

This case highlights the importance of considering GGI as a rare cause of acute upper abdominal pain accompanied by severe vomiting or retching. A high index of suspicion is essential for timely diagnosis. Prompt imaging and surgical intervention are critical to prevent serious complications. Increased awareness among clinicians can significantly improve the recognition and outcomes of this uncommon but potentially life-threatening condition. Early diagnosis is crucial to prevent serious complications, including gastric ischemia, obstruction, and perforation.

Conflict of Interests

None declared.

Data Availability Statement:

The images in [Figs. 1] and [2] are available with the authors and can be provided on request.

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Publication History

Article published online:
05 February 2026