Intussusception secondary to endometriosis of the cecum

INTRODUCTION

Intussusception in adults is a rare cause of bowel obstruction. Endometriosis of the bowel is also a rare entity that can be the cause of bowel obstruction. Here, we report a rare case of intussusception secondary to endometriosis of the cecum.

PRESENTATION OF CASE

A 40-year-old woman presented to the hospital with a one-week history of intermittent epigastric pain. On physical examination, there was a soft, round non-tender palpable mass in the right flank and abdominal computed tomography scan revealed an intussusception. We made the diagnosis of ileo-colic intussusception and performed ileocecal resection. The surgical specimen revealed a round submucosal cystic mass in the cecum and the histology showed endometriosis of the cecum.

DISCUSSION

Intussusception in adults is a rare entity present in just 1% of all patients with bowel obstruction, and 5% of all intussusceptions. In general, intussusception in adults has a pathologic lesion as the lead point and the lesion is a malignancy in 20–50% of the cases. Thus, the treatment of an intussusception in adults should be operative. Endometriosis of the bowel is a rare cause of intussusception. Small endometriosis lesions of the bowel are unlikely to cause symptoms; however, in patients presenting with bowel obstruction, urgent treatment is indicated.

CONCLUSION

Intussusception in an adult is a rare cause of bowel obstruction and intussusception caused by endometriosis is also rare. Although rare, the diagnosis of endometriosis as a cause of intussusception must be considered as part of the differential diagnosis.     

Laparoscopic treatment for intussusception of the small intestine in the adult

The term intussusception refers to a spontaneous invagination of a portion of the intestine into another bowel loop. Its incidence is higher in children, but in adults it causes 1% to 5% of intestinal obstructions. The diagnosis of intussusception in the adult is difficult due to the variability of the symptoms. The condition may be chronic, intermittent, or acute. Surgical intervention is necessary in all cases and in up to 90% of cases an organic lesion inside the invaginated part of the bowel is found to be the lead point. The laparoscopic approach offers both a diagnostic and therapeutic option. Laparoscopy may be used as the final diagnostic or therapeutic tool for intussusception in the adult.     

Idiopathic adult colo-colonic intussusception: Case report and review of the literature

INTRODUCTIONAcute colonic intussusception occurring in the absence of organic cause is uncommon in adults.PRESENTATION OF CASEWe report acute colonic intussusception in a 46-year-old female; clinical evidence of a palpable mass, abdominal pain and bloody mucoid stools appeared a few hours after hospital admission. Multislice CT-scan confirmed the clinical diagnosis and surgical exploration revealed right colonic obstruction caused by intussusception of the cecum into the ascending colon. Right hemicolectomy was performed and histopathological examination did not reveal any causative pathology.DISCUSSIONIntussusception remains a rare condition in adults, representing 1–5% of bowel obstruction and accounting for 0.003–0.02% of all hospital admissions. Intussusception occurs more frequently in the small (50–80%) than in the large bowel (12–50%). It is estimated that approximately 90% of intussusceptions in adults are secondary to an anatomical or pathological condition, of which more than half are malignant. Idiopathic cases are the exception in adults. The clinical presentation of adult intussusception differs considerably from the classic pediatric presentation of abdominal pain, palpable mass, and blood per rectum, which is rarely seen in adults. A pre-operative CT-scan showed a 10 cm intussuscepted segment of right colon. Surgical resection was considered mandatory because of severe bowel obstruction, and the theoretical possibility of occult malignancy. This approach was vindicated by the presence of widespread ischemic lesions in the wall of the resected bowel, without any obvious lead point.CONCLUSIONThere are few reports in the medical literature of acute colonic intussusception occurring in the absence of organic cause in adults.     

Adult colo-colonic intussusception caused by congenital bands: A case report and literature review

IntroductionIntussusception refers to the telescoping of a segment of bowel into the lumen of an adjacent segment. While pediatric intussusception is common and generally idiopathic, adult intussusception is exceedingly rare and is usually attributable to a pathologic lead point.Presentation of case37-year-old man who presented with abdominal pain, and was preoperatively diagnosed with a colo-colonic intussusception. Intraoperatively, the lead point was found to be congenital bands, and there was no evidence of underlying malignancy. He underwent a laparoscopic-assisted extended right hemicolectomy with side-to-side ileo-colic anastomosis.DiscussionColo-colonic intussusception is a rare cause of intestinal obstruction in adults. Patients generally present with subacute abdominal pain and obstructive symptoms, rendering the clinical diagnosis challenging. Computed tomography has been shown to be the most accurate diagnostic imaging modality. Due to the high incidence of underlying malignancy in adult colo-colonic intussusception, en-bloc resection of the involved bowel segment remains the standard of care.ConclusionCongenital bands can serve as a lead point in colo-colonic intussusception, particularly in younger adults. Prompt surgical intervention remains paramount to limit morbidity.     

Intussusception of the Meckel’s diverticulum within its own lumen: Unknown complication

IntroductionIntussusception with the Meckel’s diverticulum (MD) is a rare cause of chonic abdominal pain in the adults. We wish to present this first case of intussusception of MD within its own lumen without small bowel obstruction.Presentation of caseWe report the case of a 27-year-old man who was admitted to the emergency room due to a diffuse abdominal pain. Abdominal CT scan showed invagination of MD. The exploratory laparoscopy revealed the presence of intussusception of MD within its own lumen. Segmental resection of the small intestine was performed. The patient was discharged on the third post-operative day.DiscussionThe prevalence of MD is 1 to 4%. Diagnosis is often difficult and delayed because clinical symptoms are not specific and the diagnosis is performed mainly by imaging studies. Factors pre-disposing these patients to intussusception of MD within its own lumen include a narrow diverticulum, large diverticululm, and associated inflammation of the diverticulum. Intestinal obstruction is a more common complication in adults, whereas in children, bleeding is the more common complication. In our case, the patient had a diffuse abdominal pain without small bowel obstruction because the intussusception of MD was within its own lumen. Laparoscopy may be useful for confirming the presence of intussusception, and demonstrating the underlying organic lesion serving as the lead point.ConclusionIt is important to differentiate this rare pathological feature of MD from other entities as the treatment is surgical rather than medical. Abdominal surgeons should bear in mind this rare entity.     

Ileal lipoma - a rare cause of ileocolic intussusception in adults: Case report and literature review

The occurrence of intussusception in adults is rare,accounting for less than 5% of all cases of intussusceptions and almost 1%-5% of bowel obstruction.The condition is found in less than 1 in 1300 abdominal operations and 1 in 100 patients operated for intestinal obstruction.The child to adult ratio is more than 20:1.We report a rare case of ileocolic intussusception in an adult secondary to an ileal lipoma.     

Adult intussusception.

OBJECTIVE: The objectives were to review adult intussusception, its diagnosis, and its treatment. SUMMARY BACKGROUND DATA: Adult intussusception represents 1% of all bowel obstructions, 5% of all intussusceptions, and 0.003%-0.02% of all hospital admissions. Intussusception is a different entity in adults than it is in children. METHODS: The records of all patients 18 years and older with the postoperative diagnosis of intussusception at the Massachusetts General Hospital during the years 1964 through 1993 were reviewed retrospectively. The 58 patients were divided into those with benign enteric, malignant enteric, benign colonic, and malignant colonic lesions associated with their intussusception. The diagnosis and treatment of each were reviewed. RESULTS: In 30 years at the Massachusetts General Hospital, there are 58 cases of surgically proven adult intussusception. The patients' mean age was 54.4 years. Most patients presented with symptoms consistent with bowel obstruction. There were 44 enteric and 14 colonic intussusceptions. Ninety-three percent of the intussusceptions were associated with a pathologic lesion. Forty-eight percent of the enteric lesions were malignant and 52% were benign. Forty-three percent of the colonic lesions were malignant and 57% were benign. CONCLUSIONS: Intussusception occurs rarely in adults. It presents with a variety of acute, intermittent, and chronic symptoms, thus making its preoperative diagnosis difficult. Computed tomography scanning proved to be the most useful diagnostic radiologic method. The diagnosis and treatment of adult intussusception are surgical. Surgical resection of the intussusception without reduction is the preferred treatment in adults, as almost half of both colonic and enteric intussusceptions are associated with malignancy.     

Adult intussusception due to inverted Meckel's diverticulum: laparoscopic approach

Nowadays, laparoscopy appears to be an attractive alternative to conventional surgery in the management of small bowel obstruction. Adult intussusception is an unusual cause of intestinal obstruction, and a wide range of pathologic conditions can result with intussusception. In this report, we present a very rare case of intussusception secondary to inverted Meckel's diverticulum in an adult who underwent laparoscopic surgery. The diagnostic modalities and surgical management of intussusception are discussed.     

Intussusception in adults: institutional review

BACKGROUND: Intestinal intussusception in the adult is a rare entity that differs greatly in etiology from its pediatric counterpart. Controversy remains regarding the optimal management of this problem in the adult patient. The purpose of this study was to determine the cause(s) of intussusception and to determine the role of intestinal reduction in the management of intussusception in adults. STUDY DESIGN: A retrospective review performed at The Mount Sinai Medical Center identified 27 patients, 16 years and older, with a diagnosis of intestinal intussusception. Data related to presentation, diagnosis, treatment, and pathology were analyzed. RESULTS: There were 13 males and 14 females. The median age of the group was 52 years with a range of 16 to 90 years. Abdominal pain was the most common presenting complaint. A preoperative diagnosis was suspected in 11 of 27 patients (40%). There were 22 small bowel lesions and 5 colonic lesions. A pathologic cause was identified in 85% of patients with 8 of 22 (36%) small bowel and 4 of 5 (80%) of large bowel lesions being malignant. All small bowel cancers represented metastatic disease and all large bowel malignancies were primary adenocarcinomas. The median age of patients with malignant disease was 60 years; it was 44 years for those with benign disease. Operative treatment consisted of resection alone in 58% of patients and resection after reduction in 42%. Three patients were treated nonoperatively. CONCLUSIONS: Our data support a selective approach to the operative treatment of intussusception in adults. Colonic lesions should not be reduced before resection because they most likely represent a primary adenocarcinoma. Small bowel intussusception should be reduced only in patients in whom a benign diagnosis has been made preoperatively or in patients in whom resection may result in short gut syndrome.     

Elective laparoscopy in diagnosis and treatment of recurrent small bowel obstruction

BACKGROUND: To evaluate the feasibility, efficacy, and safety of laparoscopy in diagnosis and treatment of recurrent small bowel obstruction. METHODS: Retrospective analysis of 253 patients who underwent therapeutic laparoscopy for recurrent small bowel obstruction from June 1996 to May 2005 was carried out. Patients with acute small bowel obstruction, bowel obstruction due to tumor, and obstructed inguinal hernias were excluded from analysis. RESULTS: Laparoscopy diagnosed cause of obstruction in all except 3 (1.18%) patients. The etiology included adhesions (38%), incarcerated ventral incisional hernias (32%), Meckel diverticulum (7%), stricture (14%), volvulus (3%), intussusception (4%). One hundred sixty nine patients were managed totally laparoscopically with adhesiolysis. Therapeutic bowel intervention other than adhesiolysis was required in 84 patients, of which 33 procedures were performed totally laparoscopically and remaining 51 procedures were completed with laparoscopically guided target incision. Five patients required conversion to open celiotomy. Iatrogenic enterotomies occurred in 3 patients and small bowel perforation during manipulation occurred in 1 patient. Postoperative procedure-related complications were seen in 44 patients. There was one mortality due to postoperative arrhythmia and cardiac failure. CONCLUSIONS: Laparoscopic diagnosis and treatment of recurrent small bowel obstruction is feasible, safe, and can be performed electively in selected cases.     

Community teaching hospital surgical experience with adult intussusception: Study of nine cases and literature review

IntroductionAlthough more commonly thought of as a surgical problem affecting children, surgeons evaluating the adult acute abdomen should remain vigilante in diagnosing intussusception. In this case series, we reviewed 6 years of medical records at a community teaching hospital in order to analyze the etiology, presentation, and management of nine cases of adult intussusception.Presentation of casesMost of the patients in our series shared symptoms of nausea, vomiting, and abdominal pain. Computed tomography scan was crucial in distinguishing adult intussusception from other causes of acute abdomen. Eight patients underwent operative exploration, five of whom underwent bowel resection. One patient’s symptoms resolved with no surgical intervention. All nine patients had excellent outcomes.DiscussionAlthough detailed history and physical examination are essential in all cases of acute abdomen, CT scan findings of “target” signs are pathognomonic of intussusception. Laparoscopy should be strongly considered in select cases. Current literature suggests that reduction may be performed before resection if the lesion meets certain stringent parameters. The primary concern with regards to reduction before resection is potential embolization of malignant cells. Colonic intussusception is almost always treated with resection without reduction, while small intestinal intussusception could be treated by reduction before resection, if the small bowel lead points are less likely to be malignant.ConclusionIntussusception is a rare but serious etiology of the acute abdomen in adults. Each case should be evaluated independently according to the specific type of lead-point lesion. Excellent outcomes may be anticipated with prompt diagnosis and surgical treatment.     

Laparoscopic adhesiolysis in acute small bowel obstruction: a preliminary experience.

OBJECTIVE: The aim of this study is to evaluate laparoscopy as another tool for management of cases of adhesive acute small bowel obstruction. METHODS: Fourteen patients suffering from suspected adhesive small bowel obstruction were explored laparoscopically over a period of 24 months. The Veress needle was inserted either in a virgin part of the abdomen away from previous scars or under direct vision using an open technique. Careful inspection of the entire abdomen was done, and the small bowel was "run" in a retrograde fashion starting at the cecum. The point of obstruction was localized and adhesiolysis was performed, thus resolving the problem. RESULTS: Laparoscopic exploration was able to determine the site and cause of obstruction precisely in all 14 cases, with resolution of the problem laparoscopically in 12 patients (85.7%). Two cases were converted to open surgery (14.3%). There were no mortalities and low morbidity (7.1%). The mean hospital stay was 3.7 days. CONCLUSION: Laparoscopic surgery can be an advantageous alternative to open surgery in acute small bowel obstruction, thus providing a new technique for its diagnosis and treatment with all the advantages of minimally invasive surgery.     

Laparoscopy-assisted resection of ileoileal intussusception caused by intestinal lipoma

Intussusception is the second most common abdominal emergency in children. In contrast, it is rare in adults. Adult intussusception represents only 1%-3% of patients with bowel obstruction. Although 95% of intussusception in children is idiopathic, merely 7% of adult intussusception is considered idiopathic. Owing to vague symptoms and signs, the preoperative diagnosis of adult intussusception is difficult. Once adult intussusception is diagnosed, surgical intervention is indicated because about half of both colonic and small intestinal intussusceptions are caused by malignant lesions. In this paper, we describe a case of ileoileal intussusception caused by an intestinal lipoma that was diagnosed preoperatively by computed tomography scans and was treated successfully by laparoscopy-assisted surgery. The patient was discharged uneventfully 4 days after the operation. We recommend laparoscopy-assisted surgery as a feasible therapeutic option for adult intussusception.     

Intussusception caused by dried apricot: A case report

INTRODUCTION

An unusual cause of intussusception due to small bowel obstruction secondary to dried apricot consumption was encountered. Phytobezoar small bowel obstruction is a rare, but interesting pathology that accounts for 2–4% of small bowel obstructions (18). Even rarer, is an intussusception caused by dried fruit ingestion. We present the case of a 56-year-old female that presented with an intussusception after she ingested a large amount of dried apricots.

PRESENTATION OF CASE

The patient is a 56-year-old female with a small bowel obstruction secondary to intussusception in the distal ileum. She was taken to the operating room for a celiotomy where an intussusception of the distal small bowel was found. An enterotomy was performed which revealed dried apricots as the lead point. The intussusception was successfully reduced and the apricots removed.

DISCUSSION

Small bowel obstruction due to intussusception can be caused secondary to malignancy, Meckel''s Diverticulum, benign neoplasm, and strictures. A less common cause for small bowel obstruction due to intussusception in adults is secondary to mechanical obstruction by bezoars. Risk factors for bezoar formation include previous gastric surgery, diabetes, and mastication problems.

CONCLUSION

Bezoars are an extremely rare cause of intussusception in adults. A high level of suspicion needs to exist in the presence of a history of eating dried fruit, history of gastric surgery, diabetes mellitus, and problems with mastication. Various treatment modalities exist to treat obstructions secondary to bezoars, including open reduction and removal of bezoar via enterotomy.     

Viral small bowel intussusception: a rare cause of intestinal obstruction

Representing a rare cause of bowel obstruction, the ileal intussusception is commonly met in the pediatric surgery. Even if in children's cases the symptoms can mimick a multitude of abdominal syndromes, usually in adult cases the symptoms fit the pattern of the intestinal obstruction. This paper presents 2 clinical cases of small bowel intussusception in adult, the particularity of cases being that the pathogenesis couldn't be established first hand; the pathology exam revealed only minor inflammatory responses,including modest reactive lymph nodes in the vicinity of lesions, without further alterations. The etiology of bowel intussusception was finally attributed to viral infection with gastroenteritis, based on clinical and pathological criteria.     

Inverted Meckel's diverticulum causing intussusception in an adult

Adult intussusception is rare, making-up only about 1% of the causes of bowel obstruction intussusception, secondary to an inverted Meckel's diverticulum, is also a rare occurrence. Chronic abdominal pain, lower gastrointestinal bleeding, and recurrent obstructive symptoms may lead to an unnecessary delay in diagnosis. This case report describes a rare cause of adult intestinal intussusception due to inverted Meckel's diverticulum. Intussusception was diagnosed on emergency ultrasound of the patient, who was successfully managed with surgery.     

Intussusception in adults: a 21-year experience in the university-affiliated emergency center and indication for nonoperative reduction

BACKGROUND: While intussusception is relatively common in children, it is rare in adults. METHODS: We retrospectively reviewed the records of all patients older than 18 years with the diagnosis of intussusception between 1981 and 2001. RESULTS: Eleven patients with surgically or endoscopically proven intussusception were encountered at the University-affiliated emergency center. The patients ranged in age from 19 to 88 years with a mean age of 45 years. Males predominated by a ratio of 7:4. Most patients (82%) presented with symptoms of bowel obstruction. The mean duration of symptoms was 4.5 days with a range of 4 h to 25 days. Correct pre-treatment diagnosis was made in 82% of the patients using abdominal ultrasonography and computed tomography (CT). The causes of intussusception were organic lesions in 64% of the patients, postoperative in 18% and idiopathic in 18%, respectively. 73% of patients had emergency operations, and an attempt at nonoperative reduction was performed and completed successfully in 3 patients with ileo-colic or colonic type of intussusception. There have been no cases of morbidity or mortality in our series and no recurrence has occurred up to the present time. CONCLUSIONS: Abdominal ultrasonography and CT were effective tools for the diagnosis of intussusception. Patients with ileo-colic and colonic intussusception without malignant lesions could be good candidates for nonoperative reduction prior to definitive surgery.     

Laparoscopic management of acute small bowel obstruction

Background As minimally invasive surgery gains ground, it is entering realms previously considered to be relative contraindications for laparoscopy. We reviewed our experience with the laparoscopic approach to the management of small bowel obstruction (SBO).Methods From December 1997 to November 2002, 65 patients underwent laparoscopic treatment for SBO. The operating surgeon attempted to identify a transitional point between distended and collapsed bowel and then address the obstruction at that point.Results Postoperative adhesions were the cause of the obstruction in 44 patients. Tumor was identified in five cases, hernia in four, bezoar in three, intussusception in three, acute appendicitis and pseudoobstruction in two cases each, and terminal ileitis in one case. The diagnostic accuracy of laparoscopy was 96.9%. Thirty-four patients (52%) were treated by laparoscopy alone. Thirteen patients (20%) required a small target incision for segmental resection. Eighteen operations were converted to formal laparotomy. The mean laparoscopy time was 40 min (range, 25-160). Patients resumed oral intake in 1-3 days. The complication rate was 6.4%. There were two deaths, but none related to laparoscopy. The mean hospital stay was 4.2 days.Conclusions Laparoscopy is a useful minimally invasive technique for the management of acute SBO. It is an excellent diagnostic tool and, in most cases, a therapeutic surgical approach in patients with SBO. However, a significant number of patients will require conversion.Presented in part at the 10th annual congress of the European Association for Endoscopic Surgery (EAES), Lisbon, Portugal, 2-5 June, 2002     

Jejunojejunal Intussusception After Roux-en-Y Gastric Bypass: A Review

Small bowel intussusception is a rare long-term complication after Roux-en-Y gastric bypass, the etiology of which remains unclear. Except for one series reporting on 23 patients, case reports represent the vast majority of all cases reported so far. With this complete review of the world literature, based on a total of 63 patients including 2 of our own cases, we provide an extensive overview of the subject. The origin of intussusception after gastric bypass is different from that of intussusception of other causes, in that there is usually no lead point. It is likely related to motility disorders in the divided small bowel, especially in the Roux limb. This rare condition may cause obstruction and lead to bowel necrosis if not recognized and treated promptly. Clinical presentation is not specific. Computerized tomography scan represents the diagnostic test of choice, but surgery is sometimes the only way to establish the diagnosis. Treatment may be limited to reduction if the small bowel is viable, but resection of the affected segment is recommended on the basis of this review, since it seems to result in fewer recurrences. Knowledge of this entity and a high index of suspicion are required to make the correct diagnosis and offer appropriate treatment in a timely fashion.