2594 An Unusual Case of Small Bowel Intussusception

Abstract

INTRODUCTION: Intussusception is the telescoping of a part of the intestine into a more distal segment. The first case of intussusception was reported in 1674 by Barbette and detailed in 1789 by John Hunter. It is often classified by location into entero-enteric (65%), Ileocecal (19%), Colo-colic (9%) and finally duodeno-duodenal (<5%). It typically presents between the age of 6 and 36 months making adult presentation rare. We report a rare case of Duodeno-duodenaI intussusception secondary to tubular adenoma. CASE DESCRIPTION/METHODS: A 57 year old African American female with a history of rheumatoid arthritis and hysterectomy presents to the emergency room with complaints of epigastric pain for two days. The pain was intermittent, aggravated by food, and associated with nausea and two episodes of vomiting. She denies any other symptoms or similar episodes in the past. Last bowel movement was reported a day prior to presentation. Vital signs upon admission were within normal limits. On physical examination abdomen was soft, non distended with epigastric tenderness. Blood work on admission was unremarkable except for White blood cell count of 11.6 k/ul and Lactate level of 1.6 mmol/L. Computer Tomography (CT) scan of Abdomen showed telescoping of the apparent 2nd and 3rd portions of the duodenum compatible with intussusception (Figure 1). Patient underwent upper endoscopy with biopsies that showed a 3 cm duodenal polypoid lesion with pathology revealing tubular adenoma (Figures 2 and 3). Patient's symptoms resolved 2 day after presentation with supportive care only. Patient underwent endoscopic submucosal dissection of the lesion. DISCUSSION: Adult small bowel intussusception is a very rare entity that accounts for 5% of all cases of intussusception and 1%-5% of intestinal obstructions. The diagnosis can be challenging as symptoms are nonspecific and includes abdominal pain, nausea and vomiting. CT scan was found to be the preferred imaging study with specificity of 100% and sensitivity of up to 87% in adults. It often shows a “target sign” on the sagittal view or a sausage-shaped mass on axial and coronal views. It is always associated with a lead point such as a lipoma, hamartomatous polyps. The etiology in our case was a tubular adenoma which makes it more intriguing. Although duodenal intussusception is rare, recognition is critical for institution of appropriate therapy and prevention of complications. It should be considered in the differential diagnosis of any abdominal pain with signs of bowel obstruction.