Download Benign Causes of Adult Intussusception

World Journal of Colorectal Surgery
Volume 4, Issue 1
2014
Article 3
Benign Causes of Adult Intussusception
Lalit Kumar Mr∗
Hasan Mukhtar†
Jayant Vaidya‡
∗
Whittington Hospital, [email protected]
†
‡
c
Copyright 2014
The Berkeley Electronic Press. All rights reserved.
Benign Causes of Adult Intussusception
Lalit Kumar Mr, Hasan Mukhtar, and Jayant Vaidya
Abstract
Intussusception is a rare cause of adult intestinal obstruction and can sometimes be a surprise
finding at laparotomy. We describe five cases of adult intussusception with interesting clinical and
radiological findings. We also provide a review of the current literature with respect to presentation, diagnosis and management.
KEYWORDS: Intussusception, Benign intussusception, Causes of Intussusception, Adult intusussception
Kumar et al.: Benign Causes of Adult Intussusception
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Benign Causes of Adult intussusception
Report of five cases and literature review
Lalit Kumar
Jayant S Vaidya
Hasan Mukhtar
Department of Surgery and Medicine*
Whittington Hospital
Royal Free and University College London Medical School
Highgate Road
London N19
Correspondence to
Lalit Kumar
Email: [email protected]
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Intussusception is a rare cause of adult intestinal obstruction and can sometimes be a
surprise finding at laparotomy. We describe five cases of adult intussusception with
interesting clinical and radiological findings. We also provide a review of the current
literature with respect to presentation, diagnosis and management.
Case 1
A previously fit 60-year old Greek Cypriot lady was admitted with a 3-month history of
colicky abdominal pain associated with nausea and intermittent vomiting. She was anorexic
and had lost one and a half stones in weight. During this time she attended her GP’s
surgery on at least four occasions and 4 weeks prior to admission an abdominal and pelvic
ultrasound scan revealed multiple slightly dilated fluid/ gas filled loops of small bowel.
On admission she was unwell and dehydrated. Her abdomen was distended, diffusely
tender and demonstrated ‘erythema-ab-igne’ due to application of a hot water bottle for
chronic pain (Figure 1). There were no signs of peritonism. Bowel sounds were present and
a plain abdominal film revealed dilated small bowel loops. Blood tests were unremarkable.
A rigid sigmoidoscopy to 16 cm was normal. At laparotomy she was found to have jejunojejunal intussusception (Figure 2) of a 5 x 5cm midjejunal tumour, which was resected with
a segment of jejunum (Figure 3). Histology revealed a benign inflammatory fibroid polyp.
She was discharged on the fifth postoperative day having made an uncomplicated recovery.
Case 2
A 37-year old Chinese lady presented with a 2-year history of increasing peri-umbilical
colicky pain and associated nausea, but not vomiting. Over the 8-10 weeks prior to
admission the pain had increased considerably. She was able to eat and drink and pass
normal stools every day, although eating seemed to increase the pain.
On admission, she had peri-umbilical erythema-ab-igne and admitted to using a hot water
bottle for her pain. A soft mass was palpable in the right iliac fossa. Abdominal x-ray
revealed slightly dilated loops of small bowel, but no signs of acute obstruction. An
abdominal CT scan revealed a mixed attenuation soft tissue mass in the right flank, which
had the typical radiological appearance of an intussusception (Figure 4). A multi-lobulated
lesion suggestive of a lipoma or low-grade liposarcoma was evident at the lead point.
At laparotomy, an ileocaecal intussusception was found with ileum intussuscepting up to
the transverse colon. This could be milked back leaving a large mass in the caecum. A
limited right hemicolectomy was performed. The histopathological examination revealed a
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lipoma in the submucosa of ileocaecal valve (Figure 5 & 6). The patient recovered well and
was discharged on 6th day.
Case 3
A 34 years old Caucasian male presented with abdominal pain and diarrhoea of 3 weeks
duration. He had visited the emergency department twice in these 3 weeks at two different
hospitals and discharged with diagnosis of gastroenteritis on both occasions. Pain was
intermittent, colicky in nature and was associated with diarrhoea, anorexia and nausea.
There was no other significant past medical or surgical history. On examination, he was
tachycardic, normotensive and afebrile. The abdomen was soft, non distended with
tenderness in the right iliac fossa and lumbar region without signs of peritonism. Bowel
sounds were present and digital rectal examination was unremarkable. Plain film of chest
and abdomen did not reveal any abnormality. CT scan was obtained (Figure 7) which
showed colocolic intussusception. On laparoscopy colocolic intussusception was confirmed
and right hemicolectomy was performed due to presence of ischaemic bowel. There was no
apparent cause found for intussusception intraoperatively. Histological examination of the
specimen revealed foci of florid lymphoid hyperplasia in the submucosa of terminal ileum
and ileocaecal valve with marked enlargement of the regional lymph nodes in the area of
the caecum and ascending colon. The entire colonic mucosa showed a prominent brush
order of the surface epithelium indicating intestinal spirochetosis. No focal lesion was
identified, however, the localised infection and hyperplastic regional pericolic lymph nodes
due to intestinal spirochetosis were found to be the traction point of the intussusception.The
patient recovered uneventfully and was discharged on sixth postoperative day.
Case 4
53 years old male presented with worsening abdominal pain of two weeks duration. The
pain was in RIF pain with radiation to LIF and was associated with bloating and two
episodes of vomiting. He also complained of diarrhoea which started with the pain and
settled for few days after taking anti diarrhoeals, but then recurred. There was no similar
history of such pain in past. There was no h/o recent travel, trauma, previous abdominal
surgeries or anything suggesting malignancy. He was otherwise fit and well and was not on
any regular medications. On examination his abdomen was rigid with generalised
tenderness. There were no mass, hernia or expansile pulse noted. Bowel sounds were
reduced and digital rectal examination revealed an empty rectum. Blood test showed raised
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leukocyte count of 21.4 and CRP of 40. Rest of the FBS, U&E’s and LFT’s including
amylase were within normal limits. CXR showed free sub diaphragmatic gas and AXR
revealed dilated small bowel loops and air outlining the bowel wall. Subsequent CT scan
reported marked dilatation of ascending and transverse colon upto splenic flexure at which
point there was a focal wall thickening and stenosis extending over 9.6 cm. The overall
features were suggestive of perforated obstructing neoplasm in splenic flexure. Patient was
taken to theatres and had laparotomy and extended right hemicolectomy for a non viable
perforated caecum in addition to intussusception at the splenic flexure.
Case 5
50 year old Caucasian female presented with central abdominal pain of two weeks duration
associated with and diarrhoea and bilious vomiting for one week. Pain was crampy in
nature and in waves initially but became constant on day of presentation. There was no
history of sinister symptoms of weight loss, change in bowel habit or appetite prior to this
episode. Apart from two C-sections in the past there was no other significant past medical
history and the patient was not any regular medications. Systemic examination was
insignificant and abdominal examination revealed a palpable bowel loop with central
abdominal tenderness. There was no evidence of any hernia. Digital rectal examination
revealed loose stools but no blood or mass. CT scan reported large intramural colonc
lipoma with associated intussusception and caecal dilatation upto 7cm. Patient underwent
an extended right hemicolectomy and ileo colic anastosmosis.
Histology reported
20x60x40mm lipoma at ileo caecal valve in addition to intususscepion of large bowel into
the distal portion. There was no evidence of malignancy or atypia noted. Patient had an
uneventful post operative period and was discharged on day 5 post op.
Literature review and discussion
Intussusception is a common cause of intestinal obstruction in the paediatric age group. It is
rare in adults accounting for only 5% of all intussusceptions1. Forty five cases were found
within a cohort of 58000 operations performed from 1986-1998 in a surgical unit in
Taiwan,i.e., about 4 cases per 5000 cases seen every year2. They noted that intussusception
caused 3% of all adult cases of intestinal obstruction.
In contrast to paediatric intussusceptions, 90% of which are idiopathic, there is reportedly
an underlying cause in around 90% of adult cases, with a neoplastic lesion being the
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commonest aetiology3. Non-neoplastic processes constitute 15-25% of cases, and
idiopathic or primary intussusception about 10%4. Intussusception of the small bowel is the
commonest presentation with the majority due to benign aetiology. Colonic intussusception
is more likely to have a malignant aetiology with primary malignant lesions,
adenocarcinoma and lymphoma accounting for 50-60% of documented cases5.
Inflammatory fibroid polyps are a well described, although rare, benign cause of small
bowel obstruction6,
7, 8, 9, 10, 11,12
. A report of a series of 12 cases from South Africa13
revealed that the earlier cases were only diagnosed at laparotomy whilst more recent cases
were diagnosed more precisely pre-operatively using ultrasonography, barium meal, CT
and MRI scans.
Although intussusception typically presents as an acute surgical emergency in children the
presentation in adults is more varied and adult intussusception can present with a broad
spectrum of non-specific symptoms. A number of patients with chronic intermittent
intussusceptions describe long histories of varying symptoms including intermittent
abdominal pain, nausea, vomiting, weight loss and constipation14,3. The symptoms in many
cases are of long duration and diagnosis is often very difficult to detect clinically.
Radiological studies have a significant role to play in the diagnosis of these patients and the
appearances of an intussusception on abdominal ultrasound, CT and MRI scans are
virtually pathognomonic and
are well documented3,15,16,17, although the clinical
presentation may not always allow accurate preoperative diagnosis. The classically
described “target sign” is easily visualised in the CT scans obtained in our second case.
The treatment of intussusception in the paediatric age group has traditionally involved
using hydrostatic enemas or pneumatic reduction with surgery being reserved for those
cases in which these methods fail. More recently successful laparoscopic reduction has
been described in children18,19. There is very limited evidence of the efficacy of
laparoscopic surgery for adult intussusceptions. Case reports have been published
describing successful reduction of the intussusceptions laparoscopically but removal of the
precipitating factor has been performed extracorporeally20,21,22,23. But the authors accept
that formal laparotomy is required for malignant causes.
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The cases we have presented are excellent examples of the often insidious onset of this
disease and the diagnostic problems which it poses. In our second case, the diagnosis was
suggested pre-operatively, by clinical findings and confirmed by the characteristic images
obtained on abdominal CT scanning.
It is important to keep in mind, this rare but important cause of subacute intestinal
obstruction. Due to the insidious onset of the disease, characterised by vague abdominal
symptoms and late clinical signs the diagnosis of is often elusive. Early consideration of
this diagnosis may allow more prompt diagnosis and significantly reduce patient morbidity.
Benign lesions are the commonest cause of intussusception overall but there is a significant
association between colonic intussesception and malignancy. Identification of a colonic
intussusception pre-operatively has significant implications in the counselling of the
patients undergoing emergency laparotomy as it enables the surgeon to provide more
accurate information on the likely procedure, risks and long-term prognosis to patients.
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