An Unusual Solitary Ileal Polyp Presenting with Gangrenous Intussusception

Abstract

Intussusception is a relatively frequent cause of intestinal obstruction in infancy and early childhood. In 95% of cases the cause remains unknown. In older children there usually is a lead point that causes intussusception; Meckel`s diverticulum and hypertrophied Peyer’s patches remain some of the commonest causes. A solitary large polyp in the proximal ileum is rare and its presentation as gangrenous intussusception within just 24 hours is still more unusual. We report such an unusual case at our institute. CASE REPORT A 6-year-old Muslim male child presented in the emergency department with severe pain in the abdomen, around the umbilicus, and with multiple episodes of vomiting for one day. The patient was apparently alright one day before when he first experienced pain around the umbilicus, which gradually increased in intensity and remained persistent later on. There was an appearance of a small lump on the left side of the umbilicus accompanied with multiple episodes of vomiting, greenish-yellow in color. The patient had passed hard stools once in the early morning and had low-grade fever. There was no similar history in the past with no other major illnesses. There was no history of any local trauma or any operation performed on the child in the past. On examination, the patient was drowsy but oriented in time, place and person after deep stimulus. He had fever of 38.5 C and his pulse rate was 124 beats per minute. His blood pressure was 100/70mm of Hg. On abdomininal examination, there was a sausage-shaped mass present on the left and superior aspect of the umbilicus measuring 12cm×4cm×3cm with no distension of abdomen elsewhere. The mass was soft in consistency, not moving much with respiration. Bowel sounds were hyper-peristaltic. Per rectal examination showed an empty rectum. Clinical diagnosis of intussusception was obvious. Emergency investigations revealed a WBC count of 20,800/cumm, an Hb of 11.3 gm%, Na 139 and K 4.2 mEq/L. Plain X-ray of the abdomen showed localized air-fluid levels in the left lumbar area with no gas beyond that in the rest of the abdomen. There was no free gas under the diaphragm. A decision to perform an emergency exploration was taken after adequate resuscitation of the patient. At exploration, the following findings were noted: Proximal ileo-ileal intussusception, 15cm in length, which was gangrenous. A large solitary polyp, 4.5cm in length, was forming the apex which was totally blackened. Multiple discrete mesenteric lymph nodes. The appendix was mildly inflamed with a small worm within the lumen. The rest of the bowel was normal with no worms/polyps elsewhere. The rest of the viscera were normal. An attempt to reduce the intussusception was made by pushing back the intussusceptum but it failed. It was totally gangrenous. Eventually, the intussusceptum perforated through the serosa of the intussuscipiens and then the decision to perform a resection with end-to-end ileo-ileal An Unusual Solitary Ileal Polyp Presenting with Gangrenous Intussusception 2 of 5 anastomosis was taken. Mesenteric lynph node biopsy was taken and appendicectomy was also performed. A corrugated rubber drain was kept near the site of anastomosis. The postoperative course was uneventful and the patient made a remarkably good recovery. The drain was removed after 72 hours. Oral nutrition was started on the 4[[[th]]] postoperative day after appearance of bowel sounds. The patient was discharged after complete suture removal. At follow-up after 2 years, the patient was completely asymptomatic and healthy. On gross pathological examination, the coiled up intestine measured 20cm in length. The serosa was covered with exudates. On opening, the lumen was filled with altered blood and showed an infracted polyp measuring 6×2.5×1 cm forming the apex of the intussusceptum. The neck of the intussusception showed complete obstruction of the intestinal lumen and the surrounding segment appeared gangrenous. The appendix showed congestion with a faecolith. Figure 1 Figure 1: Gangrenous lead point: Ileal solitary polyp Figure 2 Figure 2a and 2b: Ileo-ileal intussusception getting “reduced”