Adult intussusception: A case report

Abstract

Introduction

Intussusception is a recognised cause of bowel obstruction and is significantly more common in paediatric patients. Adult intussusception is rare and requires a predisposing factor in the vast majority of patients and this may include a benign lesion, a malignant lesion or bowel wall abnormality such as inflammatory bowel disease.

Presentation of case

We present the case of a patient presenting with upper abdominal pain, nausea, vomiting and weakness. The patient had ongoing mild intermittent abdominal pain for months which was investigated with an oesophagogastroduodenoscopy (OGD) that showed gastritis. There were features of peritonism on clinical examination and this was associated with raised inflammatory markers. A Computed Tomography (CT) scan showed telescoping of the ileum with proximal bowel distension suggesting bowel obstruction. The patient underwent emergency surgical resection. Histopathology assessment did not identify a causative factor for the intussusception.

Discussion

We present a case of idiopathic entero-enteric intussusception in an adult which is not commonly seen. Clinical history of chronic intermittent abdominal pain and CT abdomen are helpful in establishing the diagnosis. Despite that conservative approach is described in the literature, surgery continues to be the only option in patients who are unstable and show signs of peritonitis.

Conclusion

Adult intussusception is not a common condition and can be difficult to diagnose. Patients with intussusception may report a relatively long period of intermittent abdominal pain that worsen acutely due to complete obstruction. CT is the most useful investigative modality to confirm the diagnosis of intussusception.

Highlights

• •Intussusception is rare in adults and has a different pathophysiology to paediatric population.
• •Clinical diagnosis can be difficult in adults but long history of intermittent abdominal pain may be suggestive.
• •CT scan is the most important investigation to confirm the diagnosis.
• •Surgical management remains the mainstay treatment especially in small bowel intussusception.

1. Introduction

Intussusception is telescoping of a proximal part of bowel into a distal segment resulting in obstruction. As little as 1 % of bowel obstruction is caused by intussusception with adult intussusception representing only 5 % of cases [1]. Unlike intussusception in the paediatric cohort which is benign in most patients, adult intussusception is secondary to an underlying pathology in up to 90 % [1]. The inducing factor is a pathology within the bowel wall that serves as a leading point which promotes invagination and telescoping [2]. Common examples of a lead point include a benign polyp, a malignant lesion, Meckel's diverticulum and Crohn's disease. Intussusception has been categorized into 4 subtypes depending on the involved bowel parts namely: enteric, ileocolic, colocolonic and sigmoidorectal intussusception [3], [4].

The majority of adult patients present with chronic abdominal pain and partial obstruction [5]. Computed Tomography (CT) has been reported as the most sensitive investigation of intussusception [2]. Furthermore, CT can differentiate between intussusception with a lead point such as a tumor versus intussusception that lacks one. Features of increased cross sectional diameter, bowel wall oedema and a mass are suggestive of the presence of a lead point [6].

While the definitive treatment of adult intussusception is mainly surgical, the choice of reduction versus en-bloc resection is controversial among surgeons. The theoretical risk associated with resection includes the risk of intraluminal and venous seeding of malignant cells in cases of malignancy. However, the presence of gangrenous segments precludes the option of reduction and necessitates resection. This case report has been reported in line with the SCARE 2020 criteria [7].

2. Case report

We present the case of a 65 year old woman who was referred to the emergency department by her family doctor for worsening upper abdominal pain, nausea and multiple episodes of bilious vomiting. The abdominal pain had started 4 months ago and was intermittent in nature with no previous vomiting. The patient described her pain as crampy with radiation to the back and right flank, and was exacerbated by food ingestion and by leaning down. It was relieved upon opening bowels and by sitting forward. Over-the-counter analgesia and Hyoscine Butylbromide 10 mg was tried by the patient but did not relieve her symptoms.

The patient's background includes Oesophagogastroduodenoscopy (OGD) which was done to investigate the pain 3 months prior to her index presentation. The OGD showed oesophagitis, gastritis and duodenitis and was negative for Helicobacter pylori. This prompted starting Proton Pump Inhibitor (PPI) treatment with Esomeprazole 40 mg twice daily. She also had a history of multinodular goitre, covid-19 infection 4 months earlier, and depression. The patient had a family history of gallbladder cancer in her mother. Her regular medications are Atorvastatin, Hypromellose eye drops, Calcium/Colecalciferol, Paracetamol/Codeine phosphate hemihydrate/Caffeine, Fluticasone furoate, Esomeprazole, Escitalopram, Loperamide, Sodium alginate/Sodium bicarbonate/Calcium carbonate and Famotidine. The patient is non-smoker who lives alone and is fully independent with activities of daily living.

On examination, there was generalised tenderness that was most pronounced in the central abdomen and in the right lower quadrant. There were no hernias, scars or stoma. The cardiovascular and respiratory examination was unremarkable. She had a respiratory rate of 18 breaths/min, saturation of 98 % on room air, blood pressure of 123/76 mmHg, heart rate of 77 bpm and was apyrexial with temperature of 36.4 °C. Blood results are shown in Table 1.

Table 1.

Blood results on admission.

Parameter	Result	Range
White blood cells (WBC)	20.7	4.4–11.3 × 109/L
Neutrophils	17.2	1.4–6.6 × 109/L
Haemoglobin (Hb)	12.8	11.7–15.9 g/dL
Platelets	348	140–440 × 109/L
Urea	10.5	2.8–8.4 mmol/L
Creatinine	78	49–90 umol/L
Sodium	137	132–144 mmol/L
Potassium	3.8	3.5–5.1 mmol/L
Alanine aminotransferase	19	30–120 U/L
Alkaline phosphatase	100	30–120 U/L
Bilirubin	19	2–20 umol/L
Amylase	31	30–120 U/L
C-reactive protein (CRP)	138	0–5 mg/L
Lactate	1.6	<2 mmol/L

Blood results showed raised inflammatory markers with WBC of 20.7 × 10⁹/L and CRP of 138 mg/L. The renal and liver function was normal except for a slightly raised bilirubin of 19 U/L.

The initial management was keeping the patient nil by mouth, inserting a nasogastric tube for decompression, starting IV fluids, analgesia and monitoring the hourly urinary output. An urgent CT abdomen and pelvis with oral and IV contrast was arranged and showed telescoping and double lumen appearance of the ileum in the right lower quadrant suggestive of small bowel obstruction (Image 1). There was an associated upstream dilatation of the small bowel measuring up to 3.5 cm in maximal transverse diameter with distal collapse. There was also a small amount of free fluid with no signs of pneumoperitoneum. The patient was booked for theatre for an emergency laparoscopy ± laparotomy.

Image 1.

Pre-operative CT showing ileo-ileal intussusception (red arrow). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)

The procedure was started as laparoscopy which showed a significant amount of free fluid with a small perforation seen in the small bowel just proximal to the site of intussusception (Image 2).

Image 2.

The intussuscepted bowel segment as viewed on laparoscopy.

3. Procedure

The procedure was performed by a consultant general surgeon who was assisted by the registrar on-call. General anaesthesia was given. Laparoscopy was performed with 3 ports, the first was a 12 mm port through a 1.5 cm longitudinal subumbilical incision in anticipation of potential need for a laparotomy incision. On intra-abdominal inspection, the abdominal cavity contained roughly 1 L of a green-yellow fluid which was evacuated with suction. The small bowel was examined in a proximal fashion starting from the ileocaecal valve until the intussusception was identified at approximately 70 cm from the ilecaecal valve. There were no signs of mesenteric fat wrapping, mass or Meckel's diverticulum. The subumbilical incision was extended by 3 cm followed by applying Alexis wound protector. Resection of a 15 cm segment of small bowel that contains the intussusception was performed. On closer inspection and palpation of the affected segment, no causative pathology was identified. There was no mass, polyp, diverticulum or signs of inflammatory bowel disease. A side-to-side handsewn double layer (continuous mucosal and continuous serosal) anastomosis was done using 3/0 PDS suture. The entirety of the abdominal cavity was washed out using normal saline. Fascial closure was done using loop 0/0 nylon while the skin was closed with 3/0 monocryl and dermabond and no drain was used.

The patient made good recovery post-operatively and was able to tolerate liquid diet on day 1 post-op and low residue diet on day 2. Bowels opened on day 1 post-operatively. Dietician advice was taken regarding oral intake and the patient was discharged home on day 4 on low residue diet for 2 weeks. There were no complications post-operatively. Follow-up and wound review was conducted 4 weeks after the surgery. The patient was compliant with the dietary advice for the first 2 weeks post-operatively and was able to tolerate normal diet following that. She reported normal bowel habit. On examination, a fully healed wound was observed and the abdomen was soft, non-tender and not distended on palpation. The patient was satisfied with the outcome at the time of follow-up and did not report any issues. No additional follow-up was required.

The pathology report showed central transmural ischaemic necrosis both recent and older intensive inflammatory reaction. This is consistent with intussusception. The surgical margins were viable with no evident necrosis.

4. Discussion

We presented the case of a patient with symptoms suggestive of bowel obstruction and features of acute abdomen on a background history of a recent diagnosis with gastritis. However, clinical examination showed signs of peritonism which was associated with raised inflammatory markers. The patient had no history of similar presentations, IBD or abdominal surgeries. However, the vague history and clinical examination was not sufficient to confirm the diagnosis albeit being highly suggestive of obstruction. Cross sectional imaging with CT was extremely beneficial in establishing the diagnosis as it showed telescoping and double lumen appearance of the ileum indicating small bowel obstruction with an associated upstream dilatation of the small bowel.

Adult intussusception is a rare entity in patients presenting with acute abdomen and is not commonly considered among the top differential diagnoses in bowel obstruction unless proven with imaging. It usually is secondary to another pathology, mostly a malignant or benign mass or can be due to another primary bowel wall pathology such as Crohn's disease. Around 65 % of cases are caused by neoplasms [8]. Other reported aetiologies include adhesions, lymphoid hyperplasia, cystic fibrosis, scleroderma, celiac disease, appendicitis, pancreatitis, and rectal foreign bodies [9]. Although paediatric intussusception can present as a triad of abdominal pain, bloody diarrhoea and abdominal mass, adult intussusception presents with vague abdominal symptoms [10]. Thus, the diagnosis of adult intussusception can be delayed as a result of the non-specificity of symptoms [11]. However, it has been suggested that adult intussusception often manifests as chronic intermittent cramping abdominal pain associated with nonspecific signs of bowel obstruction [9] which applies to the this patient.

While the symptoms and signs of a patient with intussusception are non-specific, Wang et al. have reported that intussusception presents with subacute (24.4 %) or chronic (51.2 %) history [10]. The patient herein presented in the same manner which can be helpful in considering intussusception as a stronger possibility in the differential diagnosis. However, other conditions may manifest in a similar way such as IBD, appendicitis and volvulus. This in our view emphasizes the importance of imaging in the form of abdominal CT. This is consistent with the findings of Kano et al. [3] who concluded that CT abdomen was superior to ultrasound in establishing the diagnosis and has diagnostic accuracy of nearly 100 %. However, ultrasound's accuracy increase to >90 % where there is a palpable mass [10] which is found in 24 %–42 % of cases [12].

Despite that colonoscopy has been described as one of the diagnostic and therapeutic modalities, it was not applicable in the scenario of ileo-ileal intussusception. Furthermore, the patient had signs of peritonitis which precluded conservative management. Treatment remains largely limited to surgery in enteric intussusception. In this case, the clinical findings of peritonism along with the CT findings that confirmed obstructed small bowel necessitated surgical management. The resected segment did not show any lead point. This is extremely rare as the majority of intussusception cases require a lead point over which peristalsis create telescoping of the bowel.

5. Conclusion

We presented the case of a 65 year old lady with idiopathic intussusception. The diagnosis of intussusception in an adult should be considered in patients who present with chronic or subacute and intermittent abdominal pain. CT abdomen and pelvis proved to be of high importance in confirming the diagnosis and guiding management in the form of emergency laparotomy.

Consent

Written informed consent was obtained from the patient.

Ethical approval

Not required.

Funding

No funding was received.

Author contribution

Dr Ahmed I. Dhannoon Haidaran: Consultant General Surgeon. Responsible for diagnosis and management and is the operating surgeon.

Dr Ibrahim Haidaran: Surgical Trainee. Compiling of the data and writing up the case report with review of the literature.

Guarantor

Dr. Ibrahim Haidaran.

Research studies

Not applicable.

Declaration of competing interest

There is no conflict of interest to declare.