A Rare Case of Ileocecal Intussusception in an Adult

Abstract

Question: A 91-year-old woman with ulcerative colitis in clinical and endoscopic remission on mesalazine presented with a 2-day history of severe right lower abdominal pain, nausea, and vomiting. Physical examination showed abdominal distention and tenderness in the right side of the abdomen. A computed tomography scan of the abdomen showed dilated small bowel loops and a typical target sign (Figure A, arrow), suggesting colonic intussusception and a lead point intussusception with invaginated mesenteric fat and vessels (Figure B, arrow). Colonoscopy revealed the invagination of the terminal ileum (intussusceptum) into the ascending colon (Figure C) and localized marked edematous swelling of the ileocecal valve as the lead point. The ileocecal region showed no mucosal changes suggestive of ischemia. What is the most likely diagnosis? How should the patient be managed? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. The swollen ileocecal valve was punctured with an endoscopic needle knife, causing clear fluid to leak out (Figure D, E). The submucosa was confirmed to be highly edematous and filled with fluid. The swollen mucosa then became completely deflated, and the intussusception was immediately resolved (Figure F, Video). Histologic findings of the biopsy specimens revealed no pathological findings other than edema in the submucosa and the lamina propria. No malignant cells were found in the examined fluid. There was no evidence of a causal factor of intussusception, such as bowel ischemia, inflammation, diverticulum, lesions that were either benign or malignant, or any other pathological trigger. The cause of the localized edema of the ileocecal valve was unknown. Based on these findings, the diagnosis of adult idiopathic ileocecal intussusception was made. The patient completely recovered and was discharged without procedure-related complications. No recurrence of intussusception occurred over a 3-year follow-up period. Adult intussusception represents 5% of all cases of intussusception and accounts for only 1%–5% of bowel obstructions in adults, and most cases involve identifiable etiologies such as benign or malignant tumors.1Azar T. Berger D.L. Adult intussusception.Ann Surg. 1997; 226: 134-138Crossref PubMed Scopus (677) Google Scholar In contrast, idiopathic intussusception is frequent in children, but rare in adults. Owing to the high rate of malignancy or other structural change causing adult intussusception, a surgical approach has been served as the treatment of choice.1Azar T. Berger D.L. Adult intussusception.Ann Surg. 1997; 226: 134-138Crossref PubMed Scopus (677) Google Scholar,2Lindor R.A. Bellolio M.F. Sadosty A.T. et al.Adult intussusception: presentation, management, and outcomes of 148 patients.J Emerg Med. 2012; 43: 1-6Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar However, intestinal resection surgery may be overly invasive when the intussusception does not involve neoplastic lesions.3Imasato M. Kim H.M. Higashi S. et al.Laparoscopic surgery for idiopathic adult intussusception successfully reduced by colonoscopy.J Anus Rectum Colon. 2019; 3: 49-52Crossref PubMed Google Scholar If endoscopic reduction is possible, as in our case, emergency surgery can be avoided and appropriate treatment can be performed. Therefore, a nonoperative approach with endoscopic reduction should be attempted when the lead point is thought to be benign or idiopathic. https://www.gastrojournal.org/cms/asset/f81955b8-fb7a-47f7-b5b2-a48da942c0eb/mmc1.mp4Loading ... Download .mp4 (45.01 MB) Help with .mp4 files Supplementary Video