Intussusception secondary to a carcinoid tumor in an adult patient

Small bowel intussusception - aetiology & management

PURPOSE OF REVIEW

Adult small bowel intussusception (SBI) differs in incidence, symptomatology and management from the more commonly encountered paediatric intussusception. This review spans across the multitude of causes of adult SBI, and summarises the diagnostic work-up and management options according to recent literature.

RECENT FINDINGS

There has been an increase in use of small bowel capsule endoscopy and point-of-care ultrasound for the diagnosis of acute adult SBI.

SUMMARY

A high degree of suspicion of a malignant cause of SBI is required in the adult population. Alarm clinical features include weight loss, history of malignancy, and iron deficiency anaemia. CT remains the gold standard imaging technique as it may identify the lead point and thus aid in endoscopic or surgical management. If malignancy is excluded and no lead point is identified, serology and histology may be helpful to look for inflammatory, infective and autoimmune aetiology.

Unique Presentation of Adult Ileocecal Intussusception Unveiling a Rare Culprit: A Carcinoid Tumor

Intussusception is a prominent contributor to bowel obstruction, marked by the invagination of a proximal bowel section into a distal segment. Ileocecal intussusception occurs when a portion of the terminal ileum folds into the cecum. In adults, intussusception is infrequent compared to pediatric cases, and represents a minority of bowel obstructions. Structural lead points are more commonly observed in adult intussusception compared to pediatric cases where risk factors include infection, Meckel's diverticulum, and intestinal polyps. Obstructions in adults are usually a result of benign or malignant neoplasms. In this particular case, a carcinoid tumor originating in the ileum acted as the structural lead point for intussusception. The patient underwent exploratory laparotomy resulting in a right hemicolectomy. This patient did not present with the classic triad of symptoms associated with carcinoid syndrome. In response to this particular case, a laparoscopic right-sided hemicolectomy with lymph node dissection was performed.

Neuroendocrine tumour masquerading as intussusception: A case report

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Intussusception commonly occurs in the paediatric population.

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Presentation in the adult population is likely malignant.

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It is important for an intussusception to be managed surgically in adults.

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Neuroendocrine tumour can present as intussusception in the adult population.

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Resection with lymph node clearance is needed for complete staging.

Introduction

Intussusception usually occurs in the paediatric population. When it occurs in the adult population, it is normally caused by a malignant intraluminal pathology.

Presentation of case

A 72-year-old female presented to us with right-sided abdominal pain for 3 weeks, associated with vomiting and diarrhoea. She had an appendectomy done 30 years ago and a recent myocardial infarction. Abdominal examination revealed a previous appendectomy scar and tenderness over the right lumbar region. Computed tomography showed ileocaecal intussusception. Right hemicolectomy with a double barrel stoma was performed as she was unstable intraoperatively. Histopathological examination of the tumour showed a well-differentiated neuroendocrine tumour. Subsequent PET scan showed no systemic disease and a reversal of the stoma was done. She remained disease free for a year.

Discussion

Our patient had undergone a right hemicolectomy despite the high risk of mortality, as there is a high chance of malignancy. Double barrel stoma was done, as she was unstable intraoperatively. Fortunately, she recovered well and had her stoma reversed without any further recurrence of her disease.

Conclusion

Adult patients who present with intussusception should be managed with resection, as there is a high possibility of a malignancy. Early resection should be planned to prevent further spread of the tumour.

Carcinoid tumor causing ileoceccal intussusception in an adult patient

Introduction: Little is known about adult intussusception, but current evidence suggests that malignancy, polyps, and diverticula are usual etiologies. We present a case of adult ileoceccal intussusception secondary to carcinoid tumor.

Case Presentation: A 53-year-old African American male presented with hematochezia and non-radiating constant left upper quadrant pain accompanied by nausea and vomiting. CT of the pelvis demonstrated a pathognomic ‘target’ sign, consistent with ileoceccal intussusception and early small bowel obstruction. Two years prior to this current presentation, the patient had experienced an episode of hematochezia for which he underwent colonoscopy and polypectomy, with subsequent pathology results negative for colon cancer. He denies diarrhea, constipation, weight loss, decreased appetite or skin flushing. Due to persistent symptoms of bowel obstruction, he underwent exploratory laparotomy. During the surgery a white-colored, chalky mass indicative of penetrating tumor was noted 13 cm proximal to the ileocecal valve. An extended right hemi-colectomy followed the discovery of the mass. Pathology showed a well-differentiated neuroendocrine tumor consistent with carcinoid tumor. Evaluation for metastatic disease using 5-HIAA and chromogranin A was unremarkable, and the resection of the right colon carcinoid tumor was felt to be curative.

Conclusion: It is uncommon for adults to present with intussusception; in such cases, malignancy should be ruled out as an underlying cause. Carcinoid should be listed among the other secondary causes, which include inflammatory bowel disease, diverticulitis, polyps, scar tissue, adhesions, and lipomas.

Abbreviation: CT (Computer tomography), 5-HIAA (5-hydroxyindole acetic acid), NCCN (National Comprehensive Cancer Network)

Small bowel volvulus with intussusception: an unusual revelation of neuroendocrine tumor

The primary malignant tumors of the small bowel are rare, representing 1 to 1.4% of all gastrointestinal tumors. We report a case of a 33 year-old women, admitted to our emergency department of visceral surgery for acute abdomen. The clinical examination revealed diffuse abdominal distension, defenseless, the hernia orifices were free and the rectal examination was normal. The biological test showed no hydro electrolytic disorders with normal hemoglobin and normal renal function. The abdominal CT-Scan showed signs of bowel obstruction due to a volvulus with intussusception without ischemia. The patient was operated urgently; the exploration has revealed a small bowel obstruction in the ileum with volvulus, an intussusceptum associated with a retractile mesenteritis, and the hepatic exploration found no metastases. The patient underwent a bowel resection taking away the intussusceptum with the infiltrated mesentery. The postoperative course was uneventful. The pathological result has proved a well-differentiated neuroendocrine tumor with five free nodes. Through this observation, we aim to highlight that an obstruction of small bowel with volvulus and intussusception could be exceptionally due to a neuroendocrine tumor, this complication has enabled a relatively early diagnosis in the absence of metastases and a 6-month follow-up without recurrence is a demonstration.

Jejunal Intussusception: A Rare Presentation of Carcinoid Tumor

A 55-year-old male presented to the emergency department with sudden onset of diffuse abdominal pain for one day. Physical examination was remarkable for tenderness in the umbilical region. A CT scan of the abdomen showed intussusception involving the jejunum without any mass. The patient then underwent an exploratory laparotomy. During surgery, the distal jejunum was intussuscepted with mesenteric lymphadenopathy. Liver showed nodular deposits in both lobes of the liver. The involved small bowel segment was resected with primary anastomosis and liver was biopsied. Pathological examination showed multifocal deposits of well-differentiated carcinoids in the jejunum. The liver and mesenteric deposits were positive for metastatic carcinoid. Patient recovered well without any complications.