Where Suspicion Bore Fruit- An Unusual Cause Of Abdominal Pain In A 46-Year-Old Man
S Chakraborty, P Sharma, J Roman, S Richards
Keywords
ileocolic, intestinal, intussusception, malignancy, obstruction
Citation
S Chakraborty, P Sharma, J Roman, S Richards. Where Suspicion Bore Fruit- An Unusual Cause Of Abdominal Pain In A 46-Year-Old Man. The Internet Journal of Surgery. 2012 Volume 28 Number 5.
Abstract
Abdominal pain is a common presenting complaint among adult patients presenting to the emergency department. Triage to medical versus surgical management is crucial for improved outcome. Here, we present the case of a 46-year-old man who presented with subacute onset of migratory abdominal pain, nausea, vomiting and hematochezia. Abdominal x-ray was normal but a CT scan revealed intussusception of the ileum into the transverse colon. He was treated with an emergency right hemicolectomy with side-to-side ileocolic anastomosis. Histopathology of the resected bowel revealed transmural inflammation but no cancer. We also review published literature on the epidemiology, manifestations, diagnosis and management of ileocolic intussusception in adults.
Case
A 46-year-old male presented to the emergency department complaining of severe, deep boring, nearly continuous, abdominal pain for 1 month as well as nausea, vomiting and bloody stools. The onset of the abdominal pain was sudden and occurred while he was at work. It began in his epigastric region and was migratory, radiating sequentially to the right upper, right lower, suprapubic, left lower and left upper quadrant. It was worse after eating and with movement and not relieved with rest or change in posture. He had noticed bright red blood in his stools about 4 days after pain started and continued to have bloody bowel movements, sometimes mixed with stools and sometimes frank blood. A review of systems was positive for a 4-5 day history of lightheadedness, decreased appetite, decreased frequency of urination and dark urine but negative for fever, chills, shortness of breath, or cough. He had no past history of similar pain but did have a tumor removed from the bladder (pathology unknown) and nephrolithiasis. He had never had a colonoscopy. He was on baclofen, oxybutinin, hydrochlorothiazide, lisinopril and potassium citrate. His family history was significant for a malignant tumor of an unknown internal organ in his maternal grandmother. He was a past smoker, denied recent alcohol intake, and admitted to marijuana and cocaine use as a young man. Physical examination revealed stable vital signs and marked tenderness to palpation in the suprapubic region with a lesser degree in the right and left lower quadrants of the abdomen. Rectal examination revealed no mass or hemorrhoids but was positive for occult blood. On the initial laboratory tests, he had a normal complete blood count (including differential), low glucose (68mg/dl, reference range: 90-110 mg/dl) and an otherwise unremarkable complete metabolic profile. An abdominal x-ray was normal. A CT scan of the abdomen was obtained which is shown in
Differential Diagnosis
The differential diagnosis of migratory abdominal pain worsened after eating is profound and can be divided into traumatic, infectious, inflammatory, neoplastic, autoimmune, metabolic, anatomic and vascular causes (
Clinical Course
The general surgery team was consulted and the patient underwent an exploratory laparotomy on the day of admission which revealed intussusception from the ileum to the mid transverse colon. A right hemicolectomy was performed followed by a side-to-side stapled anastomosis between the ileum and transverse colon. The patient had an uneventful post-operative recovery and was discharged home 5 days post-operatively. At his 1 week follow-up 6 days post-discharge he was doing well. Gross pathological examination confirmed intussusception of the ileum into a portion of transverse colon. The colonic and ileal wall in the area of intussusception were edematous. Microscopic examination revealed mucosal ulceration, and transmural acute and chronic inflammation. There was no evidence of malignancy (
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Discussion
Intussusception is defined as the telescoping of one segment of the gastrointestinal tract into an adjacent segment. This can either be anterograde (when a proximal part of the bowel telescopes into a distal portion) or retrograde (when the distal segment telescopes into the lumen of the adjacent proximal segment). The part of the bowel that is telescoping is called the
We conducted a literature search for published case reports and case series of ileocolic intussusception in adults. The PubMed database was searched with the term “ileocolic intussusception adult”. For case reports for which a full text was available, the patient and treatment characteristics were tabulated (
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Epidemiology
There are four main types of intussusception depending on the
Causes of ileocolic intussusception in adults reported in literature include congenital anomalies (inverted Meckel’s diverticulum), inflammation (pseudopolyp, endometriosis, surgical scar tissue, colitis and lymphadenopathy), mechanical obstruction (fecolith), benign (lipoma, lymphangioma, appendiceal mucocele, hamartoma, neurofibroma, schwannoma and giant mucocele of the appendix) and malignant (lymphoma, cecal adenocarcinoma, leiomyosarcoma and metastatic melanoma) neoplasms and iatrogenic (post-surgical) [3,8,12-48,48,48-57]. Two cases have been reported of patients with AIDS who developed an ileocolic intussusception secondary to B-cell lymphoma in the small intestine and cecum, respectively [36;51]. Hyperplastic lymphoid tissue was noted to be the cause of intussusception in another patient with AIDS [58]. In another case, a 29-year-old woman presented with symptoms of intussusception due to an inflammatory myofibroblastic tumor, a neoplasm usually occurring in the lungs [59]. There is an increasing tendency for the
The incidence of ileocolic intussusception appears to be higher in males. In one case series by Wang and colleagues, 53% of intussusception patients were males and 47% females [66]. From
Clinical Features
The most common symptoms of intestinal intussusception in order of occurrence are abdominal pain (48-50%), symptoms of intestinal obstruction (19-31%), a palpable mass (14%), hematochezia (9%), and diarrhea or constipation (5%). Interestingly, in about 5% of the patients, there was no complaint at presentation [67]. The time from onset of symptoms to presentation can be quite variable, ranging from a few hours to 6 months (
Diagnosis
From the two large institutional studies, it can be concluded that CT scan is the most accurate imaging modality for the diagnosis of ileocecal intussusception (80-90% accurate), followed by ultrasonography (50-60%), contrast enema (50%) and colonoscopy (40%) [62;63]. The classic description of intussusception on CT scan is the “target lesion” or “pseudokidney image” which represents the outer
Management
Surgery is the mainstay of treatment for ileocolic intussusception due to a higher incidence of an underlying neoplasm being the lead point and resulting bowel-wall edema, ischemia, and risk of gangrene and perforation [69]. In one study from China [62], 100% of patients with ileocolic intussusception underwent surgery. Nearly 67% underwent a right hemicolectomy, 27% a segmental small-bowel resection and one an appendectomy. In a Nepalese study, 58% of ileocecal intussusceptions were reduced successfully while 42% required resection. Colonoscopy was the most accurate diagnostic test (100%) followed by CT scan (90%) and ultrasound (70%) [70]. A single center experience in Spain reported 15 cases of adult intussusception over a 14-year period (age range 17-77 years). More than 50% of these were ileocecal. Malignant neoplasms were responsible for 50% of ileocecal intussusceptions. In a retrospective analysis from Virginia, about 18% of the 170 patients diagnosed with intestinal intussusception (including 3 with ileocolic disease) underwent surgery [8]. Patients who were found to have intussusception at surgical exploration had a longer length of intussusception (9.6cm vs. 3.8cm), a wider diameter of the involved segment (4.8cm vs. 3.2cm) and more commonly showed the presence of a lead point (53% vs. 30%) [8]. In a 1996 article, Steinwald and colleagues recommended that ileocecal (and ileocolic) intussusceptions should be managed either by an attempt at gentle reduction (if the cecum is in its normal position) or a right hemicolectomy (if the cecum is invaginated upon itself or is observed to have migrated distally), based on the relatively higher risk of an underlying malignancy driving the intussusception in the latter [71].
Conclusion
Internists and family physicians are often the first to be called to evaluate a case of abdominal pain. Ileocolic intussusception is a rare cause of abdominal pain in adults which can often be missed primarily due to the frequent lack of peritoneal signs, lack of significant toxicity and a normal abdominal radiograph. A high index of suspicion needs to be maintained and awareness that CT scan is the most accurate diagnostic modality is important for early diagnosis and surgical referral of patients for a favorable outcome.
