Adult Colocolonic Intussusception Temporally Associated With Curcumin Qingdai Use in a Patient With Ulcerative Proctitis

Abstract

Adult intussusception is rare and typically associated with an identifiable structural lead point. Emerging evidence suggests that herbal medications, including indigo naturalis, a component of curcumin QingDai, may be linked to gastrointestinal complications. We report a case of ascending colonic intussusception in a 42-year-old woman with ulcerative proctitis 5 weeks after initiating curcumin QingDai. Imaging confirmed the diagnosis, and surgical resection was required after failed conservative and endoscopic management. Histopathology revealed no structural lead point but showed inflammatory changes consistent with previous reports of indigo naturalis-associated injury. The temporal relationship and absence of alternative etiology support a possible association.

INTRODUCTION

Adult intussusception is an uncommon diagnosis, accounting for 1%–5% of all bowel obstructions and typically caused by a pathological lead point such as a neoplasm, the Meckel diverticulum, or inflammatory lesion.^1,2 Idiopathic cases without an anatomical trigger are rare. Herbal and complementary therapies, though widely used, are underreported in medical literature as potential etiologies for mechanical gastrointestinal complications.

Curcumin QingDai (CurQD), a combination of curcumin and indigo naturalis, is increasingly used by patients with inflammatory bowel disease (IBD) for its perceived anti-inflammatory benefits.^3,4 However, indigo naturalis has been associated with adverse effects, including colitis, liver dysfunction, and, more recently, intussusception.^5,6

We present a rare case of colonic intussusception temporally associated with CurQD use, potentially related to its indigo naturalis component, occurring in the absence of an identifiable structural lead point, highlighting the need for clinical vigilance regarding herbal supplement use and its potential complications.

CASE REPORT

A 42-year-old Hispanic woman with a 6-month history of ulcerative proctitis presented to the emergency department with acute, severe lower abdominal pain, and nausea without vomiting. She denied hematochezia or bowel habit changes.

Her ulcerative proctitis had initially been treated with mesalamine suppositories, but due to incomplete symptom control, she discontinued them and self-initiated CurQD 5 weeks before presentation at a dose of 2 tablets twice daily (4 g/day). She reported resolution of her symptoms after initiating the supplement, with no rectal bleeding or pain until the current presentation.

On examination, she was afebrile and hemodynamically stable. Her abdomen was soft with mild tenderness and no signs of peritonitis. Laboratory evaluation revealed mild leukocytosis (white blood cells 12.7 × 10⁹/L), with normal erythrocyte sedimentation rate, C-reactive protein and fecal calprotectin. Contrast-enhanced abdominal computed tomography showed ileocolic intussusception involving the right colon without obstruction (Figures 1 and 2).

Figure 1.

Coronal CT image of adult intussusception coronal view of the abdomen demonstrating a classic target sign in the ileocolic region, indicative of intussusception.

Figure 2.

Axial CT image of adult intussusception axial view of the abdomen demonstrating the characteristic target sign, indicative of adult intussusception.

The general surgery team recommended conservative management due to clinical stability. A Gastrografin small bowel follow-through on day 1 confirmed persistent intussusception. Despite tolerance of clear liquids and continued stool passage, serial imaging on days 2 and 3 showed unchanged findings.

On hospital day 4, patient underwent colonoscopy for possible reduction of intussusception. Colonoscopy revealed an obstructing ascending colonic intussusception with edematous, ulcerated mucosa (Figures 3 and 4). No pseudopolyps were identified, and the rectum was grossly normal. Endoscopic reduction was unsuccessful.

Figure 3.

Endoscopic view of adult intussusception endoscopic examination revealing a characteristic appearance due to the telescoping of the bowel segment. The edematous, erythematous, and partially obstructing intussuscepted segment is seen prolapsing into the lumen.

Figure 4.

Endoscopic view of adult intussusception endoscopic examination showing the telescoping bowel segment characteristic of intussusception.

Laparoscopic right hemicolectomy was performed on day 5. Operative findings included a colocolonic intussusception in the ascending colon with no structural lead point (Figure 5). Pathology revealed transmural edema, vascular congestion, and mucosal ulceration, but no dysplasia, pseudopolyps, or neoplasia. The rectum was histologically normal.

Figure 5.

Resected Right hemicolectomy specimen showing intussusception gross intraoperative image of the resected right hemicolectomy specimen demonstrating the intussuscepted bowel segment.

Postoperative recovery was uneventful. She resumed diet on postoperative day 1 and was safely discharged home in stable condition with instructions to discontinue CurQD permanently. At 4-week follow-up, she remained symptom-free without recurrent abdominal pain, had discontinued CurQD, and restarted mesalamine for ulcerative proctitis.

DISCUSSION

This case highlights a possible association between herbal therapy use in IBD and intussusception. The patient presented with radiographic and endoscopic evidence of ascending colonic intussusception 5 weeks after initiating CurQD, in the absence of IBD flare or structural pathology.

Intussusception requires either a motility disruption or a mechanical lead point. The absence of a mass or pseudopolyp in this case raises the possibility of a pharmacologically mediated motility abnormality.

Indigo naturalis has been implicated in gastrointestinal complications such as ischemic colitis, phlebitis-induced colitis, and mucosal ulceration.^7,8 In a Japanese national survey, 10 cases of indigo naturalis-associated intussusception were identified, all involving the right colon, and most requiring surgical resection⁶ A comparison of previously reported cases with the present case is summarized in Table 1. Median time to symptom onset was 5 weeks, matching our patient's timeline. Histopathologic findings in those cases—mucosal edema, vascular congestion, and transmural inflammation—mirror our observations. Two recent studies by Kondo et al and Matsuno et al also identified patients with indigo naturalis-induced intussusception, further reinforcing the potential association between CurQD use and the development of intussusception.^9,10

Table 1.

Comparison of the present case with previously reported indigo naturalis-associated intussusception cases

Age/sex	IN/CurQD dose	Time to onset (wk)	Location	Management	IN/CurQD after event
Present case, 42/F	CurQD 4 g/d	5	Ascending colon	Right hemicolectomy	Discontinued
52/M	Unknown	7	Ascending colon	Conservative	Discontinued
35/M	Unknown	Unknown	Cecum	Conservative	Continued → recurrence
37/F	2 g	8	Cecum	Endoscopic	Discontinued
26/M	Unknown	3	Cecum, ascending colon	Endoscopic	Unknown
35/M	1–2 g	4	Ascending colon	Endoscopic	Discontinued
40/M	Unknown	5	Cecum	Endoscopic	Continued
45/M	0.5 g	5	Cecum, ascending colon	Surgery	Discontinued
32/M	0.5 g	3	Ascending colon	Surgery	Discontinued
43/F	1 g	8	Cecum	Surgery	Discontinued
39/F	2 g	3	Cecum, ascending colon	Surgery	Continued

Data for previously reported cases adapted from Naganuma et al.⁶

CurQD, curcumin QingDai; IN, indigo naturalis.

Proposed mechanisms include vascular inflammation (phlebitis) leading to venous congestion and ischemia, as well as disruption of normal peristalsis due to bowel wall edema or local neuroinflammatory effects.^6,9

The temporal association, right-sided location, absence of a structural lead point, and histologic edema and vascular congestion support a possible association with indigo naturalis-containing therapy, although causality cannot be established from a single case.

In adult intussusception, surgical intervention is typically recommended due to the high likelihood of malignancy.¹¹ However, in cases lacking systemic signs or obstructive symptoms, an initial trial of conservative or endoscopic reduction is often appropriate.¹²

In our case, conservative measures and colonoscopy failed, necessitating surgery. This outcome aligns with published data where 40% of indigo naturalis-related intussusception cases required colectomy.⁶

Recurrence following continued use of indigo naturalis has been reported. Kondo et al¹⁰ described a patient who resumed CurQD post-resolution and later presented with ischemic colitis. Counseling on discontinuation is vital.

This case represents a potential safety signal for intussusception associated with indigo naturalis-containing supplements such as curcumin QingDai, warranting further investigation. In patients with IBD presenting with acute abdominal pain—particularly those in remission and using complementary therapies—clinicians should maintain a high index of suspicion. Early imaging, careful history-taking, and awareness of supplement-associated adverse effects are essential to avoid delays in diagnosis. Further pharmacovigilance and mechanistic research into indigo naturalis is warranted.

DISCLOSURES

Author contributions: K. Essilfie-Quaye contributed to the writing of the original draft. R. Lee was responsible for conceptualization and provided supervision throughout the project. H. Kalsi, M. Haddad, G. Maule, and J. Randhawa contributed to the review and editing of the manuscript. R. Lee and E. Castaldo provided supervision and critical feedback. All authors reviewed and approved the final version of the manuscript before submission. K. Essilfie-Quaye is the article guarantor.

Acknowledgments: We thank Yvette Bazikian, MD, Katy Robinson, PhD, Kasey Page, and Terri McClung, for their expertise and assistance throughout all aspects of our study and for their help in completing this manuscript.

Financial disclosure: This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

Informed consent was obtained for this case report.