Robotic Bowel Resection for Adult Intussusception with History of Marijuana Use

Abstract

Introduction:

Intussusception occurs when one segment of bowel invaginates into an adjacent segment of bowel from a lead point. Literature suggests a nonpathological lead point attributed to adult intussusception: marijuana. This report describes a unique presentation of intussusception in a patient with a history of previous surgical intervention and marijuana use.

Case Presentation:

We report a 33-year-old male with a history of surgically treated intussusception and 12 years of marijuana use, who presented to the emergency department (ED) twice with nausea, vomiting, and abdominal pain. After imaging revealed intussusception, the patient underwent multiport-robot-assisted small bowel resection. The patient had no complications and was discharged after 6 days.

Conclusion:

Intussusception can be deadly if not caught early. The use of marijuana can mislead clinicians due to similar appearing presentations. This case highlights the importance of a comprehensive patient history for abdominal pain. Additionally, it suggests placing intussusception higher in the differential for marijuana users.

INTRODUCTION

Intussusception occurs when one segment of bowel invaginates into an adjacent segment of bowel from a lead point. The precise cause of intussusception remains unknown, but it is thought that any abnormality in the bowel wall or irritation within the intestinal passage can trigger the condition. When food is ingested, and the intestines contract in a peristaltic motion, a constriction forms above the source of irritation while relaxation occurs below it. This action causes the affected portion of the intestine to fold in on itself, leading to the telescoping of one segment into another.¹

Intussusception is the most common cause of small bowel obstruction in young infants. The clinical presentation of pediatric intussusception is usually intermittent colicky pain, vomiting, bloody mucoid stools, and the presence of a palpable mass. The etiology in children is usually primary and benign. The treatment is usually nonoperative with different types of enema reduction techniques. In adults intussusception is usually associated with malignancy and may present with nonspecific symptoms.² It is relatively rare in adulthood, accounting for less than 5% of bowel obstruction and usually associated with malignancy and nonspecific symptoms.^2,3

The main causes of intussusception in adults include: carcinomas, polyps, strictures, benign tumors, Meckel’s diverticulum, and colonic diverticulum.⁴ Symptomatic adult intussusception (AI) management typically entails exploratory laparotomy or laparoscopy, followed by resection of lead point masses or areas of ischemia. Preoperative reduction using an enema, or manual reduction in the operating room, is usually discouraged due to potential risks such as perforation, seeding of tumor cells, and increased surgical complications.⁵ Although adult manifestation is rare, recurrent intussusception is rarer.⁶ Previous studies have reported that pathological lead points, such as Meckel’s diverticulum, duplication, polyp, and tumors, can lead to recurrent intussusception. Treatment with surgical bowel resection has been shown to have the lowest incidence of recurrence.⁷

However, literature has revealed a nonpathological lead point associated with AI: marijuana. The pathogenesis of cannabis on intestinal function is unconfirmed; however, studies have shown antiperistaltic effects upon activation of cannabinoid receptor type 1 (CB1) receptors located in the submucosal and myenteric nerve plexus, as well as epithelial cells, throughout the gastrointestinal (GI) tract.⁸ The major mechanism suspected is its receptor interaction in the GI tract, leading to inhibition of cholinergic neuronal pathways.⁹ Prokopchuk et al presented a similar case with multiple intussusceptions in the intestinal tract, and the only proposed causative factor was chronic cannabis use.¹⁰

With most cases of AI caused by marijuana not being associated with pathological lead points, such as our patient, reports have shown that most patients respond well to conservative management as opposed to the typical form of management, which is surgical resection. Surgical management is the typical treatment for AI because it is usually associated with a pathological lead point. In these cases of cannabinoid associated intussusception, the benefits of preventing short bowel syndrome by preserving the length of the intestine may outweigh the risks, as these cases have not been shown to be associated with pathological lead points.¹¹

REPORT OF CASE

A 33-year-old white male presented with complaints of constant, sharp, left lower abdominal pain with associated nausea and vomiting for two weeks. He had been unable to tolerate anything orally during this time. The patient had previously visited the emergency department (ED) the previous week for the same complaint for abdominal pain, nausea, and emesis, and was discharged with nausea control. The patient’s past medical history was significant for bipolar disorder, enteritis, irritable bowel syndrome, and, most importantly, intussusception with surgical intervention in 2018. The patient’s previous case of intussusception was treated operatively with a small bowel resection laparotomy at a different facility in Nevada in 2018 where no pathological lead point was found. Additionally, the patient admitted to a 12-year history of heavy marijuana use. Surgical history included cholecystectomy and a normal esophagogastroduodenoscopy and colonoscopy within the same year. His home medications at the time were amitriptyline, dicyclomine, famotidine, mirtazapine, and metoclopramide.

On the physical examination, the patient’s abdomen was soft and tender to palpation in the left lower quadrant, with guarding and hypoactive bowel sounds. Additionally, he appeared dry, fatigued, and was actively vomiting in the examination room. Comprehensive metabolic panel and complete blood count results revealed hypochloremia, hyponatremia, and leukocytosis (Table 1). The patient’s abdominopelvic computed tomography (CT) scan revealed intussusception in the left upper quadrant of the abdomen (Figure 1).

Table 1.

Significant Laboratory Results on Admission, All Other Results Were within Normal Limits

Variable	Patient’s Value	Reference Range
WBC	26.5	(3.1–9.7) 10E3/μL
RBC	5.98	(4.08–5.70) 10E6/μL
Hgb	17.1	(13.1–16.8) g/dL
Neut % (Auto)	87.5	(40.6–75.3) %
Sodium	131	(137–145) mmol/L
Potassium	4.3	(3.5–5.1) mmol/L
Chloride	62	(98–107) mmol/L
Carbon dioxide	46	(21–32) mmol/L
Anion gap	23	(5–15) mmol/L
BUN	71	(7–20) mg/dL
Creatinine	4.56	(0.66–1.25) mg/dL
Glucose	155	(70–109) mg/dL
Lactic acid (Sepsis)	1.8	(0.4–2.0) mmol/L
Calcium	9.6	(8.4–10.2) mg/dL
Total protein	10.4	(6.3–8.2) g/dL
Albumin	5.6	(3.5–5.0) g/dL
Globulin	4.8	(2.4–4.0) g/dL

Figure 1.

Preoperative abdominopelvic CT showing small bowel intussusception (red arrow).

Upon consulting surgery, the patient was admitted and for 5 days was treated with symptomatic control including, pain control, fluids, antiemetics, ulcer prophylaxis, and antibiotics (Zosyn). Blood cultures were found to be negative. On hospital day 5, the decision was made for the patient to undergo a multiport robot-assisted small bowel resection with intracorporeal anastomosis. Once access to the abdomen was achieved, the intussusception was visualized in the proximal small bowel, distal to the previously created anastomosis which had significant overlap and asymmetry. The previous anastomosis was resected as well as the area of intussusception and a functional end-to-end anastomosis was created. A 19 French JP drain was placed overlying the anastomosis and was brought out through the left lateral most port site.

The patient tolerated the procedure well and was able to tolerate a clear liquid diet on postoperative day 1. The pathology of the specimens obtained identified no polyps or masses. The day after surgery, the patient's drain output was 225 cc of serosanguineous fluid, and he began passing flatus. On postoperative day 2 the patient had a bowel movement and his drain output was down to 100 cc of serosanguineous fluid. The patient slowly progressed to a regular diet and tolerated it well. On postoperative day 6, the patient had his drain removed and was discharged home. He was advised to follow up with his surgeon in his outpatient clinic in 1–2 weeks along with his primary care physician.

DISCUSSION

With the increasing cannabis use in the United States—and rising concentrations of THC in modern preparations—the GI effects of cannabinoid receptor activation has begun to grow interest.¹² While our patient reported chronic use of inhaled marijuana, we did not identify the use of synthetic cannabinoids, which are known to exhibit even stronger CB1 receptor binding affinity¹³ which then induce a stronger GI reaction, such as nausea and emesis. It remains unclear whether synthetic cannabinoids may have a similar or more pronounced association with intussusception, though this warrants further investigation.

This case highlights how vital it is in acquiring a comprehensive patient history, including social habits, when evaluating for abdominal pain. This added information is even more important in the context of an atypical patient presentation. In the early onset of the patient’s symptoms, one could have assumed that the constant nausea, emesis and abdominal pain were connected to a small bowel obstruction, especially in the context of a surgical history of bowel obstruction. And yet, the CT imaging coupled with the lack of a pathological lead point, lack of symptom relief, and the patient’s marijuana use, all compounded to placing intussusception higher in the differential diagnosis. In light of the patient's prior resection, the differential remained broad, including the possibility of an evolving pathological lead point.

Transient intussusception without a lead point has been associated with heavy marijuana use in isolated case reports.^9,14 However, cases of persistent, symptomatic, and nonresolving cases that eventually require surgical intervention remain uncommon. Given 5 days of unchanged symptoms and stable imaging showing nonresolving intussusception, conservative management was deemed inefficient, and surgery was pursued as the next option.

Conservative management strategies for AI have been proposed in both clinical practice and the literature. While push enteroscopy and capsule endoscopy have been suggested as diagnostic tools in select cases, their application comes with a twist Shenoy et al in 2017¹⁵ acknowledged that push enteroscopy or capsule endoscopy could be considered in adults patients who were younger and mostly for the purposes of assessing for intra-luminal lesions. It is specified that capsule endoscopy or push enteroscopy should not be utilized in patients who present with obstructive patterns. Additionally, capsule endoscopy poses risk of intraluminal retention in the context of obstruction.¹⁶ Gastrografin small bowel series have been noted as a therapeutic option, especially in the pediatric population. And yet, there is little evidence in the context of its use in AI. In fact, there is very little literature dedicated towards nonoperative management of AI.¹⁷ Romano et al in 2020 utilized oral gastrografin in an adult patient with postoperative jejunal intussusception following laparoscopic low rectal resection, however, this case is the exception and not yet the norm. This solution cannot yet be favored in the context of the chronic nature and intensity of the patient’s symptoms.¹⁸

A robotic approach was chosen to facilitate safe re-entry into the abdomen, optimize visualization in the setting of prior surgery, and enable precise resection of the affected segment. Intraoperatively, no lead point was identified, reinforcing the diagnosis of idiopathic or possibly cannabis-related intussusception. However, the chronicity and lack of spontaneous resolution made operative management both diagnostic and therapeutic.

This case underscores the importance of individualized management in AI, particularly when symptoms persist despite supportive care. Even intraoperatively, it can be argued that the patient’s symptoms could have been attributed to the previous anastomosis, rather than the newly developed intussusception. However, contextualizing the patients’ decade-long use of marijuana and the already proven association with intussusception sheds light on elevating intussusception in differential diagnosis when a surgeon is exposed to atypical presentation.

While the exact mechanism linking cannabis use to intussusception remains unclear, existing evidence shows that cannabinoid receptor activation may disrupt GI motility. Previous case reports have documented recurrent intussusception in chronic cannabis users, indicating a functional rather than structural etiology in some adult cases. This challenges traditional views that AI is primarily driven by anatomical lead points requiring surgical treatment.

This case illustrates two key insights: first, the utility of robotic-assisted surgery in managing complex, recurrent intussusception in a minimally invasive manner; and second, the diagnostic value of a thorough social history—including chronic marijuana use—in shaping clinical decision-making. In patients with persistent, obstructive symptoms, early surgical intervention should not be delayed, and chronic cannabis use should raise suspicion for intussusception as part of the differential.

The potential difference this could make on the management and evaluation of abdominal pain is raising awareness among healthcare providers about the potential association between chronic cannabis use and GI complications that can facilitate earlier recognition and intervention, potentially leading to improved patient outcomes.

CONCLUSION

By broadening our understanding of potential etiological factors beyond traditional paradigms, clinicians can make more informed decisions regarding diagnostic and treatment strategies. The recognition of a potential association between chronic cannabis use and intussusception challenges conventional assumptions and highlights the need for further research to elucidate underlying mechanisms.