|Year : 2022 | Volume
| Issue : 4 | Page : 227-229
Idiopathic proximal small bowel intussusception in an adult
Aabid Ashraf, Cheena Singh, Mohd Bilal
Department of General Surgery, Maharishi Markandeshwar Medical College and Hospital, Solan, Himachal Pradesh, India
|Date of Submission||13-Jul-2022|
|Date of Decision||09-Aug-2022|
|Date of Acceptance||10-Aug-2022|
|Date of Web Publication||22-Dec-2022|
Department of General Surgery, Maharishi Markandeshwar Medical College and Hospital, Solan, Himachal Pradesh
Source of Support: None, Conflict of Interest: None
Rationale: Intussusception is fairly uncommon in adults accounting for 5% of all intussusception cases and is a cause in 1% of intestinal obstruction cases. The condition is usually associated with a pathological lead point. Idiopathic intussusception is comparatively rarer in adults. Patient Concerns: 24-year-old male with right lower abdominal pain and intermittent loose stools for fifteen days. Diagnosis: Proximal small bowel intussusception. Intervention: Resection of the involved segment with primary jejunojejunal anastomosis. Outcome: Uneventful postoperative course and full recovery. Lessons: Idiopathic intussusception, though rare in adults, should be suspected in all adults presenting with non-specific abdominal pain particularly in absence of distinct abdominal signs. Management is surgical and usually entails resection of the involved bowel.
Keywords: Intussusception, jejunum, small bowel
|How to cite this article:|
Ashraf A, Singh C, Bilal M. Idiopathic proximal small bowel intussusception in an adult. Hamdan Med J 2022;15:227-9
| Introduction|| |
Intussusception is characterised by the telescoping of a segment of the gastrointestinal tract (intussusceptum) into an adjacent one (intussuscipiens). In children, it is a leading cause of intestinal obstruction, but only 5% of all intussusceptions occur in adults and in whom it accounts for up to 1% of all cases of intestinal obstruction. Intussusception is predominantly idiopathic in the paediatric age group, accounting for up to 90% of cases. However, adult intussusception is usually associated with a lead point, a well-defined pathologic lesion in 70%–90% of cases. In adults, about 8%–20% of the total have no demonstrable cause and are idiopathic. Thus, idiopathic intussusception in adults is a rare entity. Adults can present acutely but often tend to be more chronic or intermittent with the predominant symptom being poorly localised abdominal pain, thus making it difficult to diagnose. Often, the diagnosis is missed or delayed and at times may only be revealed intraoperatively on the operating table. Contrast-enhanced computed tomography (CECT) abdomen is the investigation of choice. Surgery is the definitive treatment because of the possibility of missed intraluminal or intramural malignant lesions and recurrence.
| Case Report|| |
A 24-year-old non-smoker, a non-alcoholic male reported to the emergency department with complaints of pain in the right lower abdomen for the last 15 days along with intermittent loose watery stools and loss of appetite. Past surgical, medical and family history was insignificant. On examination, the patient had tachycardia, and the abdomen was mildly distended with diffuse tenderness and guarding. Baseline investigations, viz. complete blood count, kidney function test, liver function test, arterial blood gas analysis and electrolytes, were normal. CECT abdomen revealed proximal small bowel intussusception [Figure 1]. The patient was operated upon and subjected to exploratory laparotomy. Operative findings included jejunojejunal intussusception approximately 40 cm from the duodenojejunal junction with no identifiable lead point [Figure 2]. Resection of the affected segment with a 5 cm margin on either side of the affected bowel was performed, and jejunojejunal anastomosis was constructed. The post-operative course was uneventful, and on the 5th post-operative day, the patient was discharged. The histopathology examination confirmed no pathologic changes in the resected bowel.
|Figure 1: Coronal section on contrast enhanced computed tomography abdomen: Arrow showing bowel in bowel appearance in the proximal jejunum|
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|Figure 2: Intraoperative picture: Arrow showing intussusception in proximal jejunum|
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| Discussion|| |
In 1674, Barbette of Amsterdam first described intussusception as a disease of infancy and early childhood. The condition is relatively rare in adults. Intussusception can be divided into following types: (i) ileocolic (most common); (ii) colocolic; (iii) enteroenteric and (iv) ileocaecal.
In paediatric age group, intussusception is mostly idiopathic, while in adults, it is associated with lead points in up to 90% of cases. In the small bowel, it is usually precipitated by benign lesions such as bands, polyps, adhesions, Meckel's diverticulum and intramural lipoma., In contrast, in intussusception involving the large intestine, malignant lesions such as adenocarcinoma and gastrointestinal stromal tumours contribute to about two-third of cases.
Most cases present with abdominal pain, distension, abdominal mass and bowel disturbances. At times, the clinical picture is vague and non-specific making pre-operative diagnosis of adult intussusception very challenging. That was the case with the reported patient as well. Lower rates of preoperative diagnosis have been reported in the literature. One of the most important aspects in pre-operative workup is imaging. Plain abdominal radiographs are the usual first-line investigation, as patients frequently present with signs of intestinal obstruction. Plain films may show distended bowel loops. Ultrasonography is also widely used for diagnosis of intussusception; a 'bullseye' or 'target' sign is a characteristic on transverse view, and on longitudinal view, 'pseudo kidney' sign may be seen. The advantages of ultrasonography lie in it being non-invasive with false-negative rate approaching zero.
The investigation of the choice is abdominal CECT with a variable diagnostic accuracy ranging from 58% to 100%. Typical findings on CT scan include 'target' sign that represents a soft tissue mass surrounded by triangular fat density of the mesentery of intussusceptum, or a 'sausage-shaped' mass. Sometimes, a reniform (kidney-shaped) mass can be seen due to oedema and necrosis as a result of ischaemia.,
In children, intussusception is usually managed conservatively with pneumatic or hydrostatic reduction. However, early surgical management is essential in adults. With the high probability of a pathologic lead point, which at times can be a malignant lesion as well, surgical intervention is generally recommended in adults. The definitive treatment is surgical resection in up to 70%–90% of patients. Surgical resection of the affected bowel is preferred as to rule out any obscure microscopic pathology in the absence of an evident lead point. As with any approach to the abdomen, the use of laparoscopic versus open technique should be based on the patient's clinical status and surgeons' ability to perform the procedure safely and effectively.
| Conclusion|| |
Intussusception is a possibility in an adult patient presenting with vague abdominal pain or intermittent intestinal obstruction. There should be a high index of suspicion to avoid misdiagnosis, complications and recurrence. Early imaging and surgical management are essential. Resection should be considered to deal with potential missed lead points and to prevent recurrence.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and clinical information and any data to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]