Intussusception: as the cause of mechanical bowel obstruction in adults

Case Report: A Closed Loop Obstruction Secondary to Idiopathic Small Bowel Intussusception in an Elderly Woman

Intussusception is primarily a disease of children and is the primary cause of intestinal obstruction in the pediatric age group. It accounts for around 5-16% of cases of intestinal obstruction in adults of the western population. Most cases of adult intussusception (up to 90%) are secondary to an identified structural lesion or a lead point contrary to pediatric intussusception. Adults with intussusception present with subacute or chronic symptoms of partial obstruction. CT is the best imaging to make a preoperative diagnosis of adult intussusception. The standard treatment for adult intussusception is surgery, and non-operative reduction should not be attempted. Here, we present a rare case of idiopathic small bowel intussusception in a 50-year-old woman. She presented with crampy abdominal pain for one-week duration. It was associated with frequent vomiting of bilious matter. She claimed to have had similar symptoms for the past 2 months and had repeatedly visited nearby health facilities. She had an abdominal CT, which suggested a complicated small bowel intussusception. Exploratory laparotomy was done, and there was a small bowel intussusception and an inflammatory stricture at the end of the intussusceptum, which is believed to form a closed-loop like obstruction. The intussusceptum was resected en-bloc then end-to-end jejuno-jejunal anastomosis was performed. This case report makes physicians aware of this rare condition in adults. So that they have a high index of suspicion when a patient presents with symptoms of subacute or chronic intestinal obstruction and inform that abdominal CT should be done in these circumstances and surgery is the mainstay of treatment. Our case is unique, and there is no report in the literature similar to ours.

Lipoma causing ileocecal intussusception and its endoscopic resection

Introduction

In adults, intussusception is a rare disorder, and it might lead to acute mechanical intestinal obstruction, (AMIO) which is not typically considered in the differential diagnosis. Our case report presents a rare, fully endoscopic management of an ileocecal intussusception without any further surgical intervention. Endoscopic manipulations of such distant lesions under correct indications will surely avoid unnecessary surgery and increase patient comfort.

Case description

A 58-year-old male was admitted with complaints of nausea, vomiting, abdominal pain, and distention. Physical examination, blood tests and radiological assessments revealed the patient was suffering from AMIO. The cause of AMIO was ileocecal intussusception due to an ileal lipoma. After intussuscepted segment was uncluttered by endoscopic pneumatic reduction(ER), ileal lipoma was resected colonoscopically. The patient was discharged without any complications.

Discussion

Intussusception may appear because of benign or malignant etiologies. Cases in which malignancy is ruled out, endoscopic resection can be utilized safely in diagnosis and treatment. Endoscopic resection will also save the patient from unnecessary and costly surgical interventions.

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Colonoscopic treatment for lipomas located in the terminal ileum is not impossible.

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Endoscopic resection for suitable patients under favorable conditions may result with total cure.

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Endoscopic treatment might save patient from undergoing further surgical intervention.

Invaginación sigmoidea en un adulto. ¿Está indicada la reducción endoscópica preoperatoria?

Introducción. La invaginación intestinal o intususcepción es el deslizamiento de una parte del intestino dentro de otra adyacente. Es la causa más común de obstrucción intestinal en niños entre 3 meses y 6 años de edad, con una baja incidencia en adultos, correspondiente al 1 % del total de los cuadros obstructivos en el adulto. Su localización en colon es poco frecuente, pero conviene prestar especial atención por su asociación a lesiones malignas. Caso clínico. Varón de 39 años que acude a Urgencias con cuadro de obstrucción intestinal secundario a una invaginación en sigmoide. Se intenta reducción endoscópica, sin éxito, por lo que se indicó cirugía urgente, realizando sigmoidectomía y anastomosis colorrectal. El resultado anatomopatológico informó un adenoma de gran tamaño como causante de la invaginación. Conclusión. Existen controversias respecto al manejo endoscópico en invaginación intestinal en los adultos, especialmente en el colon, debido al elevado porcentaje de etiología tumoral maligna, recomendándose actualmente la resección en bloque sin reducción, para minimizar el riesgo de potencial siembra tumoral.

Adult Left Colocolic Intussusception Successfully Managed by Left Hemicolectomy and Primary Anastomosis

Intussusception, although quite common in children with the classic triad of cramping abdominal pain, bloody diarrhea, and palpable masses, is a rare cause of acute abdomen with myriad presentations in adults. It is defined as the telescoping of a proximal segment of the gastrointestinal (GI) tract, called the intussusceptum, into the lumen of the adjacent distal segment of the GI tract, called intussuscipiens. Due to its different manifestations and time course, adult colonic intussusception often poses a diagnostic challenge for emergency doctors. The treatment of colonic intussusception in adults typically involves surgery, often with bowel resection and anastomosis followed by a defunctioning loop ileostomy. We report a case of left-sided colocolic intussusception secondary to a tubular adenoma as the lead point, which was successfully treated by resection and primary anastomosis. The pathological diagnosis of the lesion was reported as adenocarcinoma and resected bowel margins were found free of the tumor.

Most Adult Intussusceptions are Caused by Tumors: A Single-Centre Analysis

Background

Adult intussusception is less common than paediatric intussusception. The aim of this study was to explore the clinical presentation, aetiology, diagnosis and treatment of adult intussusception.

Methods

Adults (>18 years) with intussusception treated by surgical or conservative measures were included from January 2005 to January 2018, and the manifestation, types, diagnosis and treatment of adult intussusception in our centre were reviewed.

Results

A total of 150 patients with adult intussusception were included in this study. The clinical manifestations included 111 cases (74%) of abdominal pain, 38 cases (25.3%) of bloody stool, 37 cases (24.7%) of bowel obstructions, 33 cases (22%) of abdominal distension, 29 cases (19.3%) of nausea and vomiting, 19 cases (12.7%) of an abdominal mass, and 12 cases (8.0%) of diarrhoea. The types of intussusception were classified into 36 cases (24%) of enteric intussusception, 87 cases (58%) of intestine-colon intussusception and 27 cases (18%) of colonic intussusception. Surgical intervention was applied in 139 cases (92.7%), including 115 patients who underwent open surgery, and laparoscopy-assisted surgery was performed in 24 patients. The main pathogenesis of intussusception was malignant tumors in 51 cases (36.7%) and benign tumors and polyps in 49 cases (35.3%).

Conclusion

Malignant and benign tumors are the main causes of adult intussusception. Abdominal CT is the preferred evaluation method for the preoperative diagnosis of this condition. The choice of surgical procedure depends on the location and type of intussusception.

An appraisal of the presentation and management of adult intussusception at a Nigerian Tertiary Hospital

Background

Intussusception in adults is considered rare in surgical practice. It is the causative lesion in a small proportion of cases of intestinal obstruction and lower gastrointestinal bleeding. In the last decade, the incidence of adult intussusception appears to be increasing at our centre.

Aims

This study aims to document the pattern of presentation and management outcome of adult intussusception at our institution during the last decade. We also observed the occurring trends of this lesion.

Patients and Methods

This was a 10-year retrospective study of consecutive adult patients with intussusception seen at our institution from July 2008 to June 2018. Information on biodata, clinicopathological features and management outcome retrieved from case notes and pathology records were analysed on a personal computer using SPSS version 23.

Results

Twenty adult patients who had intussusception were seen during this period. There were 9 (45%) males and 11 (55%) females giving a male-to-female ratio of 1:1.2. The mean age of presentation was 45 (range 18-66) years. Clinical features were abdominal pain (85%), abdominal distension (80%), vomiting (70%), rectal bleeding (70%) and palpable abdominal mass (35%). Majority of patients (70%) presented with features of intestinal obstruction. Idiopathic intussusception (55%) accounted for more than half of the cases with the jejunoileal variety (30%) as the most common pathological type. One patient who had intussusception in the postoperative period was treated with manual reduction at laparotomy. Bowel resections were performed in the remaining 19 (95%) patients.

Conclusion

Adult intussusception is still uncommon in our general surgical practice. Bowel resection is the mainstay of treatment.

Adult intussusception: a systematic review and meta-analysis

BACKGROUND

Perhaps partly because intussusception in adults is rare, optimal treatment remains controversial. The aim of this study was to determine the appropriate surgical procedure for adult intussusception.

METHODS

A systematic search was undertaken using PubMed, Embase, and Web of Science from 1/1980 to 12/2016. Adults (> 15 years) with intussusception treated by surgical or conservative measures were included.

RESULTS

One thousand two hundred twenty-nine patients were identified from 40 retrospective case series. Pooled rates of malignant and benign tumors and idiopathic etiologies were 32.9% (95% CI 28.6-37.4), 37.4% (95% CI 32.7-42.3), and 15.1% (95% CI 11.7-19.3), respectively. Pooled rates of enteric, ileocolic, and colonic location types were 49.5% (95% CI 41.8-57.2), 29.1% (95% CI 23.0-36.1), and 19.9% (95% CI 16.3-24.1), respectively. Pooled rates of malignant tumors in enteric, ileocolic, and colonic intussusception were 22.5% (95% CI 18.3-27.3), 36.9% (95% CI 27.3-47.6), and 46.5% (31.1-62.6), respectively. Metastatic carcinoma was the main cause of malignant tumor in enteric intussusception. Conversely, primary adenocarcinoma was the main cause of malignant tumor in ileocolic and colonic intussusception. Considering the high rate of malignancy of colonic intussusception the majority of the studies surveyed recommend en bloc resection without reduction to avoid potential intraluminal seeding or venous tumor dissemination. Pooled rates of postoperative complications and mortality were 22.1% (95% CI 17.5-27.5) and 5.2% (95% CI 3.7-7.4), respectively.

CONCLUSION

Whereas enteric intussusception can be managed by reduction followed by resection, colonic intussusception should be resected en bloc. Due to the intermediate forms between enteric and colonic intussusception, a selective approach is recommended. Surgery remains the mainstay in adult intussusception.

[Intussusception followed by intestinal obstruction in adults]

AIM

To evaluate the effectiveness of complex preoperative diagnostics and medication of intussusception followed by intestinal obstruction in adults with the choice of surgical repair and analysis of the outcomes depending on the causes of intussusception.

MATERIAL AND METHODS

15 intussusception patients aged 19 - 86 years were enrolled. Mean age was 52.7 years. Patients were hospitalized within 12 hours - 1-2 weeks after onset of the disease. Diagnosis was established on the basis of complaints, anamnesis, objective and additional survey. All patients underwent abdominal X-ray and ultrasound. Intestinal obstruction at admission was diagnosed in all patients, and only 1 (6.7%) of them had intussusception.

RESULTS

Medication and additional survey contributed to detection of intussusception followed by intestinal obstruction in 13 (86.7%) out of 15 patients prior to surgery. All patients underwent urgent or delayed surgery. Small intestine resection was performed in 9 patients, 2 patients underwent resection of small intestine with submucosal tumor (1) and Meckel's diverticulum (1) after intussusception repair. Right-sided hemicolectomy was performed in 3 patients, sigmoid colon resection with lymph nodes dissection - in 1 patient. The cause of intussusception followed by intestinal obstruction were epithelial and stromal tumors (9), less often metastasis of melanoma (2), Meckel's diverticulum (1) and functional bowel disorders (1). Postoperative complications arose in high risk patients hospitalized after 24 hours from onset of the disease and present concomitant diseases and malignancies. 1 (6,7%) patient died.

Intestinal Intussusception: Etiology, Diagnosis, and Treatment

Intussusception is defined as the invagination of one segment of the bowel into an immediately adjacent segment of the bowel. Idiopathic ileocolic intussusception is the most common form in children and is typically managed with nonoperative reduction via pneumatic and/or hydrostatic enemas. In the adult population, intussusception is uncommon and occurs more often in the small intestine than in the colon. It is associated with lead point pathology in most symptomatic cases presenting as bowel obstruction. When lead point pathology is present in adult small bowel intussusception, it is usually benign, though when malignant it is most frequently due to diffuse metastatic disease, for example, melanoma. In contrast, adult ileocolic and colonic intussusception lead point pathology is most frequently primary adenocarcinoma when malignant. The diagnosis is typically made intraoperatively or by cross-sectional imaging. With increasingly frequent CT/MRI of the adult abdomen in the current era, transient and/or asymptomatic intussusceptions are increasingly found and may often be appropriately observed without intervention. When intervention in the adult population is warranted, usually oncologic bowel resection is performed due to the association with lead point pathology.

Small bowel intussusception from renal cell carcinoma metastasis: a case report and review of the literature

Background

Renal cell carcinoma is the most frequent malignant neoplasia of the kidney accounting for 90 % of all renal solid tumors. Metastases from renal cell carcinoma are rarely located in the small bowel and generally their clinical presentation includes bleeding and obstruction. Intussusception in adults is an extremely rare pathological condition and only 30 to 35 % of small bowel intussusceptions are derived from malignant lesions.

Case presentation

We report here a clinical case of a 75-year-old white man hospitalized for anemia and subocclusion. An abdominal ultrasound and computed tomography showed a small bowel intussusception. During a surgical exploration, a polypoid lesion was found to be the lead point of the intussusception. His small intestine was resected and a functional side-to-side anastomosis was performed. The histological features of the surgical specimen confirmed the diagnosis of metastatic renal cell carcinoma.

Conclusions

Small bowel intussusception from renal cell carcinoma metastasis should always be considered in the setting of unexplained intestinal subocclusion in patients with a history of renal cell carcinoma.