Idiopathic entero-colic intussusception: imaging findings in an abdominal emergency

Толық мәтін

BACKGROUND

Adult intussusception is an uncommon condition of abdominal emergency [1].

Intussusception consists of the invagination of a bowel segment (intussusceptum) and its mesentery into the lumen of a distal portion (intussuscipiens), because of abnormal mobility of peristalsis [1, 2].

It can involve any part of the intestine, but it usually occurs at the coupling between a mobile loop and a fixed retroperitoneal segment [1, 3]. Among adults, intussusceptions are frequently associated with an organic lesion common in children, whereas they are less frequently encountered in adults: symptoms tend to be non-specific, making the diagnosis more challenging [4, 5].

 

DESCRIPTION OF THE CASE

Anamnesis:

A 37-year-old female patient was admitted to the emergency room complaining of four-days abdominal pain which had increased in the last hours. She reported no fever but noticed changes in her bowel habits, alternating diarrhea, and constipation.

 

Diagnostic assessment and differential diagnosis.

To exclude any possible cause of intestinal obstruction a CT exam examination was performed before and after the administration of intravenous iodinated contrast medium. CT showed an entero-colic invagination involving the ileocecal valve and the cecum with diffuse edematous thickening of colonic parietal walls; edematous strains in the adjacent peritoneal fat, satellite lymphadenopathies levels, and a small amount of fluid collection in the right iliac fossa were also present (Fig 1).

 

Figure 1. Abdominal CT, portal phase. On sagittal MPR (a), notice the entero-colic invagination with the involvement of the mesenteric fat and vascular structures. Thick oedematous walls, stranding of the surrounding fatty tissue (b), satellite nodes (11 mm in c)

 

Multiplanar reconstruction (MPR) showed the “target” appearance of the intestinal walls (Fig 2).

 

Figure 2. Oblique sagittal MPR, orthogonal to the intussusception, shows the “target sign” as a consequence of the alternating of oedematous walls and mesenteric fat.

Interventions.

Because of the rapid progression of the clinical signs, a surgical treatment was suggested, and a laparoscopic right colectomy was performed. Oral intake was started with fluids on the second postoperative day and solid food on the third postoperative day.

 

Follow-up and outcomes.

The patient was discharged on the sixth postoperative day. No complications were observed. Histology showed inflammatory changes of the intestinal walls with reactive satellite nodes; no other diseases were associated with the intussusception.

 

DISCUSSION

Adult intussusception is a very uncommon cause of intestinal blockage. In contrast to pediatric patients where intussusception is primary and benign, adult intussusception, particularly of the colon, has a high probability of neoplasia, therefore it leads to operative management which is often necessary.

In some patients, conservative treatment by reduction is also recommended, provided that the bowel appears viable, in the rest of the cases reduction should not be attempted if there are signs of inflammation or ischemia of the bowel wall.

In this case, we performed a laparoscopic right colectomy.

Oral intake was started with fluid on the second postoperative day and solid food on the third postoperative day. On the sixth postoperative day, the patient was discharged. No complications were observed. According to the location, intussusception can be classified as entero-colic, when limited to the small bowel, colo-colonic, if it involves the colon, and entero-colonic, which can be ileo-caecal and ileo-colic [1, 2]. The obstruction of venous blood flow can lead to edema and ischemia of the involved intestinal loop, and eventually, necrosis may develop [6].

Intussusceptions are more common in children: they are mostly idiopathic and classically present with the triad of cramping abdominal pain, currant jelly-like faces, and palpable sausage-like abdominal mass [6, 7].

Adult intussusceptions, on the other hand, are very rare, accounting for about 5% of total cases [5, 8]; they may manifest with long-standing non-specific abdominal symptoms (such as nausea, vomiting, bowel habit changes, abdominal distension, gastrointestinal bleeding), which make the diagnosis more challenging [4, 6]. In children, intussusceptions are mostly idiopathic [6].

In adults, intussusceptions are generally associated with both benign and malignant diseases in most cases; instead, idiopathic forms are less common and generally involve the small bowel, contrary to our case. Imaging is fundamental for the diagnosis, especially for the most problematic cases [9]. Abdominal CT is considered the modality of choice since it can evaluate the site of intussusception, its extension, and the bowel segment involved [10]; also, it can demonstrate the presence of a leading point and is important to exclude possible complications, such as bowel wall ischemia and perforation. The invagination of the intussusceptum into the intussuscipiens appears on CT as a “target” due to the alternating of intestinal walls and mesentery fat, when observed on a plane perpendicular to the main axis of the involved segment [1].

In contrast to pediatric patients in which intussusception is primary and benign, adult intussusception (particularly of the colon) has a high probability of being associated with neoplastic disorders [6]. Therefore, a surgical approach is often necessary.

In some patients, conservative treatment by reduction is also recommended, after providing that the bowel appears viable; in the rest of the cases, the reduction should not be attempted if there are signs of inflammation or ischemia of the bowel walls.

 

CONCLUSION

Idiopathic entero-colic intussusception is a rare abdominal urgency in adults. Symptoms can be non-specific and long-standing, which may delay the correct diagnosis. In these cases, imaging plays a central role in the diagnosis.

Some CT findings, such as a mass with a target appearance, can be suggestive.
Laparoscopic surgery is comparable with open surgery in the setting of right colectomy. The obvious advantages of laparoscopic surgery are the lower surgical site infection rate, shorter nasogastric tube duration, less postoperative pain, and better aesthetic results. The safety and efficacy of laparoscopic right colectomy in an emergency with bowel occlusion is possible in the hands of expert surgeons.

Авторлар туралы

Rosario Balzano

Radiology Unit, “Dimiccoli” Hospital of Barletta.

Email: ro.balzano@gmail.com
Италия, Viale Ippocrate 15, 70051, Barletta (BT), Italy.

Francesco Lattanzio

General Surgery Unit, “Dimiccoli” Hospital of Barletta.

Email: fralattanzio@hotmail.com
Италия, Viale Ippocrate 15, 70051, Barletta (BT), Italy.

Giacomo Fascia

Department of Clinical and Experimental Medicine, Foggia University School of Medicine.

Email: giacomo.fascia@unifg.it
Италия, University School of Medicine, Viale L. Pinto 1, 71121 Foggia, Italy.

Manuela Montatore

Department of Clinical and Experimental Medicine, Foggia University School of Medicine.

Email: manuela.montatore@unifg.it
Италия, University School of Medicine, Viale L. Pinto 1, 71121 Foggia, Italy.

Marina Balbino

Department of Clinical and Experimental Medicine, Foggia University School of Medicine.

Email: marinabalbino93@gmail.com
Италия, University School of Medicine, Viale L. Pinto 1, 71121 Foggia, Italy.

Federica Masino

Department of Clinical and Experimental Medicine, Foggia University School of Medicine.

Email: federicamasino@gmail.com
Италия, University School of Medicine, Viale L. Pinto 1, 71121 Foggia, Italy.

Domenico Mannatrizio

Department of Clinical and Experimental Medicine, Foggia University School of Medicine.

Email: dr.mannatrizio@gmail.com
Италия, University School of Medicine, Viale L. Pinto 1, 71121 Foggia, Italy.

Giuseppe Guglielmi

University of Foggia

Хат алмасуға жауапты Автор.
Email: giuseppe.guglielmi@unifg.it
ORCID iD: 0000-0002-4325-8330

Medical Doctor, Full Professor of Radiology.

Department of Clinical and Experimental Medicine.

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