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.     

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.     

An intestinal carcinoid causing transient jejunal intussusception in an adult—A case report

IntroductionTransient jejunal intussusception in an adult is a rare clinical finding as reported in the English literature. The diagnosis is usually a matter of exclusion given the extremely rare nature of this medical condition.Presentation of the caseA young female presented to our hospital with abdominal pain and distention of six months duration. The episodes were intermittent in nature and resolved with conservative management. The aetiology remained obscure until a computerized tomography(CT) scan diagnosed a small bowel intussusceptionIntraoperatively a small bowel tumour was identified and resected. Pathology confirmed an intestinal carcinoid of the small bowel with no evidence of metastatic disease.DiscussionTransient jejunal intussusception is a rare finding with only eight reported cases in the English literature. All previously reported cases have been ascribed to benign aetiologies and to our knowledge this is the first case of a malignancy causing transient jejunal intussusception. The management is usually conservative unless an actual cause for the intussusception can be ascertained. The diagnosis is usually one of exclusion and CT scan remains the gold standard in eliciting a diagnosis.ConclusionTransient jejunal intussuception in adults is an extremely rare pathological condition and the diagnosis is usually entertained as a matter of exclusion.     

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.     

Adult intussusception induced by invagination of the side to side jejuno-jejunostomy after previous total gastrectomy with Roux-en-Y oesophago-jejunostomy

Aim-Background

Adult intussusception (AI) is an unusual and challenging condition that presents a diagnostic preoperative dilemma. It is expected to be found in 1/30.000 of all hospital admissions, 1/1.300 of all abdominal operations, 1/30–1/100 of all cases operated for intestinal obstruction, and in one of 20 cases in children.

Case report

A 72-year-old woman presented with a 2-month history of colicky abdominal pain, vomiting and constipation. She had undergone a total gastrectomy with Roux-en-Y oesophago-jejunostomy for gastric carcinoma 10 years earlier. An erect abdominal X-ray displayed a dilated small bowel loop, whereas urgent abdominal computerized tomography (CT scan) raised the suspicion of a volvulus. She underwent emergency laparotomy which revealed intussusception of the side-to-side entero-enterostomy of the Roux-en-Y loop into the adjacent small bowel (jejuno-jejunal). The intussusception was carefully reduced and a segmental small bowel resection due to ischaemia was performed. No malignant disease (local, regional or distant) was identified. It is believed that the intussusception was secondary to the presence of the previous side-to-side jejuno-jejunostomy. No other clear nidus or trigger was found on histological examination of the resected bowel segment.

Conclusions

AI remains a rare cause of persistent or intermittent chronic abdominal pain. Although intussusception per se has a favourable prognosis, the definitive prognostic factor lies in the nature of the lesion leading to the process. Treatment usually requires resection of the involved bowel segment. Reduction can be attempted in small bowel intussusception, providing the segment involved is viable and malignancy is not suspected or found.     

Two unusual cases of adult intussusception

Adult intussusception is very rare. We report 2 unusual cases, a 58-year-old man with a transverse colo-colonic intussusception caused by a malignant sessile polyp that also had an asymptomatic synchronous neoplasm of the kidney, and an 18-year-old female with an ileocecolic intussusception caused by acute appendicitis. This report stresses the point that intussusception in adults may represent an underlying malignancy. The age of the patient and the anatomic location of the intussusception provide significant input as to the etiology and hence the most appropriate surgical procedure.     

Post Colonoscopy Colonic Intussusception Reduced via a Laparoscopic Approach

Intussusception occurs when a mass in the bowel is pulled forward by normal peristalsis, with resultant invagination of the involved bowel wall. In the absence of a mass, intussusception may be caused by functional disturbances without gross mural abnormality. Colo-colonic intussusception in adult is relatively rare and usually secondary to a definable lesion, the majority of which are malignant in nature. Idiopathic intussusception in adults is rare and its pathogenesis is poorly understood.We present a case report of an adult colo-colonic intussusception occurring after colonoscopy, which was treated successfully with laparoscopic reduction. We speculate that the intussusception was induced by post-polypectomy mucosal edema acting as a lead point and therefore can be treated without resection.     

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.     

Small bowel intussusception: what is the role of laparoscopy?

Small bowel intussusception in adults is a rare surgical disease which almost always occurs as a complication of either benign or malignant lesion of the bowel that is working as a leading point. In adults, the surgical approach consists of the resection of the bowel involved to ensure the excision of the lesion below. The authors report a case of ileocecal intussusception occurred in a young woman, 35 years old, observed for abdominal pain and signs of small bowel occlusion. She underwent surgical resection of the ileocecal segment with laparoscopic approach. The authors discuss the feasibility of the laparoscopic approach in this rare surgical disease and its benefits in terms of patient's postoperative comfort and outcome.     

Colo-colic intussusception secondary to colon lipoma: A case report

Introduction and importanceIntestinal intussusception is rare in adults and it is associated with lead points affecting the colon in around 17% of patients. Lipomas are very rare benign tumors which may act as lead points for intestinal intussusception. Indeed, the incidence of intestinal intussusception is much rare when caused by lipomas.Case presentationOur patient is a 29-year-old male, previously healthy and admitted for severe right lower quadrant abdominal pain of 2-day duration. Computed tomography (CT) scan of the abdomen and pelvis showed large mass of fat consistency containing colon structure.Clinical DiscussionUrgent laparotomy was opted during which colo-colic intussusception was diagnosed and right hemicolectomy with primary ileocolic anastomosis was performed. Pathology report showed that intussusception was induced by a colon lipoma. Patient had an uneventful hospital stay and was discharged on post-operative day 5.ConclusionThus we recommend that colo-colic intussusception caused by lipoma be considered in the differential when diagnosing adults with right lower quadrant pain.     

Manual laparoscopy-assisted intraoperative reduction for adult ileocolic intussusception with ileal adenoma: A case report

IntroductionAdult intussusception is a rare condition with a pathological lead point. Intraoperative reduction of adult intussusception can eliminate the need for extensive or invasive resection. We safely performed a manual laparoscopy-assisted intraoperative reduction that allowed functional preservation of tissue.Presentation of caseA 70-year-old woman with dull right lumbar pain at regular intervals and right lower quadrant abdominal tenderness was admitted to our hospital. The ileum exhibited enhanced wall thickening and invagination into the ascending colon on computed tomography. Emergency laparoscopic surgery was chosen to treat the ileocolic intussusception. First, the right colon was mobilized. Second, the ileocecal region was pulled through a 4-cm right pararectus incision. Third, the edge of the intussusceptum was gently manipulated back upstream without tearing. After reduction, a soft mass was recognized on palpation at the lead point, located 10 cm proximal to the ileocecal valve. Ileocecal resection was performed, and a laterally spreading tumor was observed in the resected specimen. The histological diagnosis was high-grade tubular adenoma. The postoperative course was uneventful.DiscussionAdult intussusception has a pathological lead point, and curative treatment generally includes resection of the lesion. Complete or partial intraoperative reduction can avoid or shorten bowel resection and allow functional preservation of the tissue.ConclusionManual laparoscopy-assisted intraoperative reduction with a minilaparotomy was safely performed, which eliminated the need for extensive or invasive resection.     

Ileocolic intussusception due to giant ileal lipoma: Review of literature and report of a case

INTRODUCTIONIntussusception in adults accounts for less than 5% of all intussusceptions. It occurs when a segment of intestine invaginates into itself.PRESENTATION OF A CASEWe report a case of ileocolic intussusception in an adult caused by a giant ileal lipoma.DISCUSSIONIntussusceptions can be classified as ileocolic, ileocecal, colo-colic and ileo-ileal. Most are due to neoplasms (60% malign and 24–40% benign). In the colon, the possibility of malignancy is higher than in small intestine.Lipomas are the most common benign mesenchymal intestinal tumors, accounting for less than 5% of all gastrointestinal tumors. They are more frequent in colon than small intestine. Small lipomas (less than 2 cm) are usually asymptomatic. Larger lesions may produce symptoms such as abdominal pain, obstruction or intussusception. Lipomas can be diagnosed with endoscopy, capsule endoscopy, barium enemas, CT and US.CONCLUSIONIntussusceptions in adults is a rare condition, most of them are caused by a malign neoplasms followed by benign neoplasms. US and CT are useful for diagnosis. Surgery is mandatory.     

Enteric duplication cyst as a leading point for ileoileal intussusception in an adult: A rare cause of complete small intestinal obstruction

Duplication of alimentary tract (DAT) presenting as an ileoileal intussusception is a very rare clinical entity. Herein, a case of an ileoileal intussusception due to DAT is presented. A 32-year-old woman was hospitalized due to diffuse, intermittent abdominal pain, vomiting and constipation for 3 d associated with abdominal distention. Plain abdominal X-ray revealed dilated small bowel. Abdominal computed tomography showed grossly dilated small bowel with “sausage” and “doughnut” signs of small bowel intussusception. She underwent laparotomy, with findings of ileoileal intussusception due to a cystic lesion adjacent to the mesenteric side. Resection of the cystic lesion along with the affected segment of intestine, with an end to end anastomosis was performed. The histopathology was consistent with enteric duplication cyst. This case highlights the DAT, although, an uncommon cause of adult ileoileal intussusception should be considered in the differential diagnosis of intussusception in adults, particularly when the leading point is a cystic lesion.     

Cecal gastrointestinal stromal tumor causing ileocolic intussusception in an adult: A rare case report

Introduction and importanceCecal gastrointestinal stromal tumors (GIST) constitute a rarer subtype of all GISTs. Rarely, it can present with ileocolic intussusception in adults making it a challenging diagnosis due to non-specific clinical features.Case presentationA 30-year previously healthy woman presented with lower abdominal pain and a distended abdomen who was subsequently diagnosed with ileocolic intussusception on a CT scan. Intraoperatively, a pedunculated polypoid hard mass was identified in the cecum and thus, a standard right hemicolectomy was performed with the suspicion of malignancy. Histopathology of the resected mass confirmed CD117 negative, spindle type GIST.DiscussionCecal GIST presenting in the form of ileocolic intussusception is rare. Contrast-enhanced CT scan is the preferred imaging modality for the evaluation of patients with suspected GIST to determine the extent of the tumor, the presence or absence of metastatic disease alongside evaluation of the possibility of complete resection. Adjuvant imatinib therapy following complete resection decreases the disease recurrence.ConclusionIntussusception in an adult can be the first manifestation of underlying malignancy like GIST. Complete surgical resection of the tumor with a negative margin offers long-term survival.     

Intestinal Intussusception as a Complication of Typhoid Fever

Typhoid fever is a severe febrile illness caused by Salmonella typhi. Although ileal perforation and bleeding are seen more frequently, intestinal intussusception is a very rare complication of typhoid fever.

A male patient was admitted to hospital due to abdominal distension and pain. Abdominal computerised tomography revealed ileal intussusception. The patient underwent exploratory laparotomy. Ileal intussusception was determined and segmental ileal resection was performed. Examination of the resected ileal segment revealed multiple ulcerous lesions that led to intussusception. The postoperative course was uneventful. The operative treatment is the subject of debate because of insufficient evidence. We recommend segmental bowel resection because of the underlying pathology.     

Sigmoid endometriosis in a post-menopausal woman leading to acute large bowel obstruction: A case report

IntroductionEndometriosis is usually a disease involving women of reproductive age. Colonic endometriosis is a rare sequelae. It usually presents vaguely with nonspecific abdominal pain, dyspareunia, fecal tenesmus, rectal bleeding or painful defecation. There are very few case reports of sigmoid endometriosis in the literature, more so ones involving post-menopausal women. Our report highlights such a case, mimicking a malignant rectosigmoid stricture leading to a large bowel obstruction.Case presentationA 63 year old lady was referred by her General Practitioner for further investigation of recent altered bowel habit. She underwent an incomplete colonoscopy due to stricturing in the sigmoid. She subsequently was admitted with abdominal pain, distension and vomiting, with imaging consistent with a large bowel obstruction secondary to a stricturing mass within the rectosigmoid which was suspicious for malignancy. An emergency laparotomy and Hartmann’s procedure was performed. She had an uncomplicated post-surgical recovery. Histology revealed no underlying malignancy, but confirmed colonic endometriosis.ConclusionThis case report shows that colonic endometriosis, although rare, can be significantly infiltrative and lead to complications such as a large bowel obstruction. Diagnosing this condition can be challenging and usually requires histological confirmation.     

Antegrade jejunojejunal intussusception inside a retrograde jejunogastric intussusception (double intussusception)—A rare case report

IntroductionJejunogastric intussusception through a gastrojejunal stoma along with a jejunojejunal intussusception (intussusception within an intussusception) is a rare but serious complication of previous gastric surgery such as gastrojejunostomy and Billroth II gastrectomy. The incidence of which is less than 0.1%.Case presentationAn elderly male presented with an abdominal lump, diffuse abdominal pain and vomiting for one-day duration. Ultrasound and CECT abdomen revealed dilated stomach with jejunojejunal intussusception herniating into stomach. Emergency laparotomy was done with manual reduction of intussusception loops and roux- en-y anastomosis.DiscussionThe number of cases reported in literature involving a jejunogastric intussusception following gastric surgery was about 300.Furthermore, there have been only two reported cases of jejunogastric intussusception along with jejunojejunal intussusception. The rarity of this clinical event makes it imperative for a high index of suspicion in patients presenting with abdominal pain following gastric surgery.ConclusionThe mortality of this condition ranges from 10% to 50%. Hence prompt diagnosis and early surgical intervention prevents vascular compromise and bowel gangrene.     

Intussusception secondary to a carcinoid tumor in an adult patient

INTRODUCTIONIntussusception in adult patients represents 5% of all intussusceptions and 1–5% of bowel obstructions in adults. In contrast to pediatric patients, 90% of the time, in adults, it's caused by well-established pathologic mechanisms, such as carcinoma, polyps, diverticula, Meckel diverticula, stenosis, or benign neoplasms. Small intestine intussusceptions are more frequent, but colonic intussusceptions are caused 50% of the time by malignant neoplasms, especially adenocarcinoma.PRESENTATION OF CASEWe present a 70-year-old woman, with no relevant familial history, who presented with a 3-day symptomatology consisting of epigastric, colic, diffuse, abdominal pain of moderate intensity, which progressed till reaching a severe intensity, also referring abdominal distension, nausea, and gastrointestinal-content vomits.DISCUSSIONIn adult patients, the exact mechanism of intussusception is unknown in 8–20% of the cases, however, secondary intussusception can occur with any lesion of the intestinal wall or any irritant factor in its lumen that alters normal peristaltic activity and that could serve as a trigger to start an intussusception of one bowel segment over another the most common site is the small intestine.CONCLUSIONIntussusception represents an unusual problem in adult patients; it requires a high clinical suspicion, mainly as a differential diagnosis in patients with intestinal obstruction, and it clinically presents as a subacute or chronic illness. CT represents the most useful diagnostic tool. An attempt to perform reduction procedures in small intestine intussusceptions can be done, however, in ileocolic or colonic intussusceptions, a formal resection of the segment is recommended.     

A case report of small bowel obstruction secondary to congenital peritoneal band in adult

IntroductionSmall bowel obstruction (SBO) is common in adult surgical procedures, mainly due to postoperative adhesions. Acute SBO in adults without history of abdominal surgery, trauma or clinical hernia is less common and has various etiologies. Congenital band is an extremely rare cause.Presentation of caseA 56-year-old man was admitted to our hospital with a two-day history of abdominal pain and bilious vomiting. He had no history of abdominal surgery or any other medical problems. A contrast-enhanced CT of the abdomen showed a distention of small bowel loops with transition point in the right hypochondrium. Distended loops of small bowel were located in the left side of the abdomen, whereas collapsed loops was located in the right side. The normal bowel wall enhancement was preserved. After initial treatment with intravenous fluid and nasogastric suction, he was operated. At laparoscopy a band obstructing the ileum was clearly observed. This anomalous band extending from gallbladder to transverse mesocolon caused a small window leading to internal herniation of the small bowel and obstruction. The band was coagulated and divided. Postoperative outcome was uneventful and the patient was discharged on the second postoperative day. There was no recurrence of symptoms on subsequent follow-up.DiscussionCongenital peritoneal bands are not frequently encountered in surgical practice and these bands are often difficult to classify and define. Diagnosis of acute intestinal obstruction due to CPB must be included in the differential diagnosis in any patient with no history of abdominal surgery, trauma, clinical hernia, inflammatory bowel disease or peritoneal tuberculosis.ConclusionDespite technological advances in radiology preoperative diagnosis remains difficult, however the diagnosis of SBO due to CPB must be considered in any patient with no history of abdominal surgery, Trauma or clinical hernia consulting for occlusive syndrome. The laparoscopic approach should be intended initially for its feasibility and benefits.     

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.