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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 15  |  Issue : 4  |  Page : 227-229

Idiopathic proximal small bowel intussusception in an adult


Department of General Surgery, Maharishi Markandeshwar Medical College and Hospital, Solan, Himachal Pradesh, India

Date of Submission13-Jul-2022
Date of Decision09-Aug-2022
Date of Acceptance10-Aug-2022
Date of Web Publication22-Dec-2022

Correspondence Address:
Aabid Ashraf
Department of General Surgery, Maharishi Markandeshwar Medical College and Hospital, Solan, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hmj.hmj_59_22

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  Abstract 


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

How to cite this URL:
Ashraf A, Singh C, Bilal M. Idiopathic proximal small bowel intussusception in an adult. Hamdan Med J [serial online] 2022 [cited 2023 Feb 1];15:227-9. Available from: http://www.hamdanjournal.org/text.asp?2022/15/4/227/364691




  Introduction Top


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.[1] 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.[2] In adults, about 8%–20% of the total have no demonstrable cause and are idiopathic. Thus, idiopathic intussusception in adults is a rare entity.[3] 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 Top


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 Top


In 1674, Barbette of Amsterdam first described intussusception as a disease of infancy and early childhood.[1] The condition is relatively rare in adults.[4] 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.[2] In the small bowel, it is usually precipitated by benign lesions such as bands, polyps, adhesions, Meckel's diverticulum and intramural lipoma.[2],[5] In contrast, in intussusception involving the large intestine, malignant lesions such as adenocarcinoma and gastrointestinal stromal tumours contribute to about two-third of cases.[6]

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.[7] One of the most important aspects in pre-operative workup is imaging.[2] 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.[4]

The investigation of the choice is abdominal CECT with a variable diagnostic accuracy ranging from 58% to 100%.[3] 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.[8],[9]

In children, intussusception is usually managed conservatively with pneumatic or hydrostatic reduction. However, early surgical management is essential in adults.[10] 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.[11] 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 Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, et al. Intussusception of the bowel in adults: A review. World J Gastroenterol 2009;15:407-11.  Back to cited text no. 1
    
2.
Yakan S, Caliskan C, Makay O, Denecli AG, Korkut MA. Intussusception in adults: Clinical characteristics, diagnosis and operative strategies. World J Gastroenterol 2009;15:1985-9.  Back to cited text no. 2
    
3.
Erkan N, Haciyanli M, Yildirim M, Sayhan H, Vardar E, Polat AF. Intussusception in adults: An unusual and challenging condition for surgeons. Int J Colorectal Dis 2005;20:452-6.  Back to cited text no. 3
    
4.
Potts J, Al Samaraee A, El-Hakeem A. Small bowel intussusception in adults. Ann R Coll Surg Engl 2014;96:11-4.  Back to cited text no. 4
    
5.
Lianos G, Xeropotamos N, Bali C, Baltoggiannis G, Ignatiadou E. Adult bowel intussusception: Presentation, location, etiology, diagnosis and treatment. G Chir 2013;34:280-3.  Back to cited text no. 5
    
6.
Gupta RK, Agrawal CS, Yadav R, Bajracharya A, Sah PL. Intussusception in adults: Institutional review. Int J Surg 2011;9:91-5.  Back to cited text no. 6
    
7.
Eisen LK, Cunningham JD, Aufses AH Jr. Intussusception in adults: institutional review. J Am Coll Surg 1999;188:390-5. doi: 10.1016/s1072-7515(98)00331-7. PMID: 10195723.  Back to cited text no. 7
    
8.
Gayer G, Zissin R, Apter S, Papa M, Hertz M. Pictorial review: Adult intussusception – A CT diagnosis. Br J Radiol 2002;75:185-90.  Back to cited text no. 8
    
9.
Wang N, Cui XY, Liu Y, Long J, Xu YH, Guo RX, et al. Adult intussusception: A retrospective review of 41 cases. World J Gastroenterol 2009;15:3303-8.  Back to cited text no. 9
    
10.
Lindor RA, Bellolio MF, Sadosty AT, Earnest F 4th, Cabrera D. Adult intussusception: Presentation, management, and outcomes of 148 patients. J Emerg Med 2012;43:1-6.  Back to cited text no. 10
    
11.
Hong KD, Kim J, Ji W, Wexner SD. Adult intussusception: A systematic review and meta-analysis. Tech Coloproctol 2019;23:315-24.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

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