Cystic lymphangiomas of the cecal cause intussusception in adults

A rare case of adult ileal-ileal intussusception secondary to inflammatory fibroid polyp (IFP): A case report

Adult intussusception is a rare entity that is almost always associated with a demonstrable lead point. There has been a notable association between adult intussusception and inflammatory fibroid polyp (IFP) or Vanek’s tumour. These polyps are benign tumours arising from submucosa, comprising of mesenchymal cells like fibroblasts and numerous variably prominent small blood vessels along with chronic inflammatory cells commonly eosinophils. Inflammatory fibroid polyps are uncommon; moreover, these polyps causing secondary intussusception in an adult is still rarer. Clinical manifestations of IFP vary based on size and location within the GI tract. Here, we report a case of inflammatory fibroid polyp of ileum, presented as acute on chronic pain abdomen in a 38-year-old woman. The rareness of the disease made it a clinical challenge to subject the patient to laparotomy. However this patient underwent resection of the intussuscepted small bowel with primary anastomosis. The rareness of non-malignant condition being the cause for adult ileo-ileal intussusception and the clinical challenge associated with it makes it a case worth reporting.

Intussusception is a rare phenomenon in adults and usually presents with bowel obstruction. Unlike pediatric intussusception, adult intussusception (AI) is seldom idiopathic and frequently associated with secondary causes such as benign and malignant tumors. AI accounts for 5% of all cases of intussusception and almost 1%–5% of all cases of bowel obstruction. We hereby present the rare case of a 42-year-old female patient with ileoileal intussusception caused by an inflammatory myofibroblastic polyp. We also delve into a review of literature on AIs, touching different common and uncommon types as well as their diagnostic modalities and therapeutic options.

Intussusception is an uncommon cause of intestinal obstruction in adults. The etiology of this disease differs from the children. Thus, its management depends on the possible etiology and is different from pediatric cases. We aimed to study the clinico-histopathological spectrum ofthe tumors and tumor-like lesions in the intussusception in adults. A retrospective review of the adult (> 18years) intussusception cases was performed. The clinical data and follow-up were obtained. The histopathology was reviewed along with the special stains and immunohistochemistry for ascertaining a histopathological diagnosis. Fifteen cases of adult intussusception were identified from 107 resected specimens of adult intestinal obstruction. The mean age was 44.5years with a male/female ratio of 1.1:1. A definitive pathology could be ascertained in 80% of the cases (n = 12/15). Eight cases had benign non-neoplastic etiology (53.3%) (33.3% tumor-like lesions) while seven cases (46.7%) had neoplastic etiology (20% benign neoplastic; 26.7% malignant neoplastic). All cases of colonic or enterocolic intussusceptions were associated with neoplasia whereas 90% of the enteric intussusceptions occurred due to benign non-neoplastic causes. CONCLUSIONS: Non-neoplastic causes are predominant in the enteric intussusceptions while neoplastic causes are more commonly associated with colonic or enterocolic intussusceptions. The post-operative histopathological examination concludes on the adequacy of the index surgery or the provision of further management if required.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasm of the gastrointestinal (GI) tract (1% to 2% of GI malignant tumors). They are most commonly located in the stomach (50 to 60%) and rarely in the small intestine (20-25% of all cases). The hallmark of most GISTs is their positivity for KIT (CD117) and DOG-1. Intussusception occurs rarely in adults with an incidence of approximately 2-3 per 1L per year. It represents 5% of all intussusceptions and is the cause of 1% of all intestinal obstructions. Ileocolic intussusception in adults is a unique variant in which most cases have a malignant lead point. In our case, we report an elderly patient presenting with intestinal obstruction, and imaging showed ileocecal intussusception with a solid nodular growth arising from the ileum. On exploration, the tumor was intraluminal arising from the ileum with ileocecal intussusception. Adhering to oncological principles, a right hemicolectomy was performed. The final pathologic diagnosis indicated the GIST of the ileum. Immunohistochemistry (IHC) showed CD117 negative and DOG-1 positive. Bowel obstruction due to intussusception in adults is rare. GIST in the ileum causing intussusception is unusual with a poorer prognosis than other GISTs. Intussusception in adults obstructing with small intestinal GIST which is CD117 negative makes it interesting and even rare. The diagnosis of intussusception and GISTs causing obstruction in adults is delicate, and timely surgical treatment can be vital. Given a high risk of malignancy, primary surgical resection using oncologic principles presents the best option in this scenario.

Pathologies of gastrointestinal tract are various and affect patients of different ages. Both of these conditions influence the imaging modalities of gastrointestinal tract that underwent relevant changes during recent years. Magnetic Resonance (MR) and Computed Tomography (CT) techniques, optimised for gastrointestinal imaging, are playing today an increasing role in the evaluation of gastrointestinal disorders, and several studies have shown the advantage of these techniques over tradition barium fluoroscopic examinations secondary to improvements in spatial and temporal resolution combined with improved bowel distending agents. Based on recent literature and guidelines, there is a change of paradigms regarding the diagnosis of esophagus and gastrointestinal cancer towards CT, whereas for small bowel imaging in inflammatory disease MRI with a new focus on Diffusion Weighted Imaging (DWI) are the most important imaging modalities, because DWI can be easily implemented in standard MRI for routine use to further enhance the diagnostic accuracy in disease assessment [1–4]. CT and MRI play an important role also in functional disorders. In particular, the recent development of faster MRI pulse sequences provides rapid, real-time imaging of the gastrointestinal tract, pinpointing areas of stricture and providing valuable information on motility. This special issue is devoted to current and emerging techniques in gastrointestinal tract, focusing on some selected topics that are both interesting and challenging: neoplastic pathologies, chronic inflammatory diseases, functional pathologies, and nontraumatic emergency causing occlusion. The first section covers cross-sectional imaging of the gastrointestinal tract in neoplastic disease, including lymphoma, both through a review (“Radiological Features of Gastrointestinal Lymphoma” by G. Lo Re et al.) and through an original paper (“Staging of Primary Abdominal Lymphomas: Comparison of Whole-Body MRI with Diffusion-Weighted Imaging and 18F-FDG-PET/CT” by A. Stecco et al.) and small-bowel neoplasms (“Small-Bowel Neoplasms: Role of MRI Enteroclysis” by A. Faggian et al.). The imaging of hepatocellular carcinoma after locoregional treatments is also reviewed (“CT Appearance of Hepatocellular Carcinoma after Locoregional Treatments: A Comprehensive Review” by D. Marin et al.). Cross-sectional imaging modalities are fundamental also in the management of patients with inflammatory bowel disease (IBD) from the first diagnosis and throughout the entire course of the disease. In this sense, MRI, owing to the lack of ionizing radiation, represents the main technique in young patients with IBD who may require multiple studies over a lifetime. New imaging of chronic inflammatory pathologies is focused on Crohn's disease, where the imaging is essential also in scoring the activity of disease (“3D-EAUS and MRI in the Activity of Anal Fistulas in Crohn's Disease” by M. E. Alabiso et al.; “Assessment of Disease Activity in Small Bowel Crohn's Disease: Comparison between Endoscopy and Magnetic Resonance Enterography Using Mria and Modified Mria Score” by A. Scardapane et al.). Some functional pathologies are also discussed: achalasia and pelvic floor disfunction (“Imaging in the Evaluation of Endoscopic or Surgical Treatment for Achalasia” by D. Palladino et al.; “MR Imaging in Diagnosis of Pelvic Floor Descent: Supine versus Sitting Position” by F. Iacobellis et al.). Finally nontraumatic emergency causing occlusion is discussed in three different papers, with emphasis on the role of MDCT and dynamic MRI (“Intussusception in Adults: The Role of MDCT in the Identification of the Site and Cause of Obstruction” by V. Valentini et al.; “A Novel Diagnostic Aid for Detection of Intra-Abdominal Adhesions to the Anterior Abdominal Wall Using Dynamic Magnetic Resonance Imaging” by D. Randall et al.; “Adhesions to Mesh after Ventral Hernia Mesh Repair are Detected by MRI but Are Not a Cause of Long Term Chronic Abdominal Pain” by O. Langbach et al.). The contributions of this special issue could stimulate the spread of new imaging modalities in daily practice, pinpoint technical aspects, and share some strategies to optimise CT and MR protocols. Roberto Grassi Antonio Pinto Lorenzo Mannelli Daniele Marin Maria Antonietta Mazzei

Introduction Intussusception is telescoping or invagination of one part of the intestine (intussusception) into an adjacent section (intussuscipiens) and it may present as a life threatening condition. Intussusception is so rare in adults and small intestine intussusception in adults is usually due to benign entity; whereas in large intestine, malignant neoplasms can be the etiology. Here, we reported a rare case of adult jejunojejunal intussusception due to a jejunal villous adenoma polyp in an Iranian female patient. Case Presentation A 33-year female Iranian patient referred to emergency department in Gastroenterology and liver diseases Research Center, Shahid Beheshti University of Medical Sciences with extreme abdominal pain, nausea and constipation. Plain abdominal computed tomography (CT) scan revealed a mass suggesting intussusception in the jejunum. Balloon association enteroscopy showed two 10 mm and 40 mm polyps in jejunum. The polyp was a villous adenoma confirmed by pathology. Exploratory laparotomy revealed jejunojejunal intussusceptions and exploratory laparotomy with jejunoileal anastomosis was performed. Conclusions Nonspecific symptoms of an adult intussusception might result in a late diagnosis and imaging modalities including CT scan play a significant role in the diagnosis. Surgical operation is the best treatment in adult intussusception leading to the best results.

Gastrointestinal intussusception is an uncommon clinical entity in adults and is interestingly distinct from its paediatric form. In adults an identifiable lead lesion is found in the majority of cases, of which a significant percentage are malignant. Its treatment is thus different from that of paediatric intussusception. The present study reviews our experience of treating adult intussusception. A retrospective review of patients with a postoperative diagnosis of gastrointestinal intussusception between January 1997 and December 2002 was conducted. All patients under the age of 18 and cases of rectal prolapse were excluded. During the 5-year period, there were nine cases of intussusception. There were four male and five female patients, with a mean age of 63.8 years (range 37-85 years). Less than half of the patients (44.4%) presented with acute symptoms. The most common symptoms were abdominal pain and distension. The symptoms were intermittent in 77.8% (7 of 9) of patients. Only two patients had a palpable abdominal mass, while another had signs of acute intestinal obstruction. Computed tomography was the most useful imaging modality, identifying intussusception in six out of six patients. Eight patients had lead lesions occurring at the ileocaecal junction resulting in ileo-colonic intussusception. Of these eight, four were malignant (two adenocarcinomas and two lymphomas). There was one sigmoid-rectal intussusception secondary to adenocarcinoma. All patients were treated operatively. Seven patients were treated with en bloc resection. Although uncommon, surgeons need to be aware of the epidemiology and treatment options for adult intussusception. The symptoms and signs are often non-specific and the surgeon might be faced with the diagnosis only at laparotomy. Computed tomography is the most useful imaging modality. An identifiable organic lesion is present in most cases, of which more than 50% are malignant (especially in the large bowel). Operative treatment is thus prudent. En bloc resection is recommended for ileo-colonic and colo-colonic intussusception. There is, however, a role of initial reduction in selected patients with ileo-ileal intussusception.

Adult colo-colonic intussusception caused by congenital bands: A case report and literature review

Adult intussusception is a rare condition characterized by the telescoping of one segment of the intestine into an adjacent segment. Prompt recognition and intervention are crucial due to the potential for serious complications. The presentcase is of adult ileocolic intussusception in a 47-year-old male patient who underwent appendectomy three weeks prior. The patient presented with constipation, lower abdominal pain, and vomiting. A transabdominal ultrasound revealed characteristic sonographic features, including a target appearance at the transverse view and the pseudokidney sign of the longitudinal view associated with the presence of reactive lymph nodes. Doppler ultrasound indicated no internal flow, suggesting possible ischemia. This case highlights the role of ultrasound in the initial evaluation of adult intussusception and emphasizes the need for further imaging modalities for detailed anatomical evaluation and lesion identification.

Despite improvements in imaging modalities, causative lead points in adult intussusception may be difficult to diagnose. Such lead points can be malignant, causing recurrence or metastases if left unresected. We describe a case of transient adult jejunojejunal intussusception, in which intraoperative endoscopy was used to confirm the absence of a lead point. A 39-year-old woman with a history of laparoscopic oophorectomy presented with epigastric pain, nausea, and vomiting. Contrast computed tomography revealed jejunojejunal intussusception, with no visible lead point. Spontaneous reduction was confirmed during exploratory laparoscopy. After lysis of adhesions, intraoperative peroral jejunoscopy was performed with the surgeons' assistance. Endoscopy confirmed the absence of tumor, and bowel resection was avoided. No recurrence has been observed during 24 months of follow-up. Intraoperative endoscopy may provide additional reassurance for the absence of a lead point in cases where preoperative enteroscopy cannot be performed and no lead points can be identified on imaging.

Adult intussusception is a rare entity which is distinct from paediatric cases in incidence, The overall incidence of intussusception in adulthood has been estimated to be around 2–3 cases/1,000,000 population/year. Ileocolic intussusception in adults is a unique variant in which nearly 100% of cases have a malignant lead point. In our report we present a case of ileocolic intussusception in a 60-year-old female patient caused by a GIST located in the terminal ileum, acting as the apex of intussusception. The female patient was admitted to hospital for abdominal pain, vomiting, nausea, and inability to defecate. The result of CT scan of the abdomen and pelvis showed ileal intussusception, which was confirmed peroperatively. Bowel resection was performed. The final pathologic diagnosis indicated the gastrointestinal stromal tumor of the ileum. The diagnosis of intussusception in adults is delicate, and timely surgical treatment can be vital. Patients with the palpable abdominal mass, digestive tract obstruction, gastrointestinal bleeding, or lead point computed tomography must undergo a surgical examination. Given a high risk of malignancy, primary surgical resection using oncologic principles presents the best option for the treatment of ileocecal intussusception in adults.

Adult intussusception is rare, accounting for approximately 5%-16% of all cases. Unlike pediatric intussusception, which is predominantly idiopathic, most adult cases are associated with organic lesions, nearly half of which are malignant. Idiopathic intussusception without a lead point is uncommon but appears to be increasingly recognized. We report a case of idiopathic adult ileocolic intussusception that mimicked cecal carcinoma in imaging studies. A 63-year-old male with a history of gastric cancer recurrence presented with a 3-month history of abdominal pain. Contrast-enhanced computed tomography (CT) revealed circumferential thickening of the right colon, forming a "target sign," and invagination of the ileocecal region into the right colon, suggesting ileocolic intussusception. Colonoscopy identified a nodular lesion presumed to be cecal carcinoma; however, the biopsy did not provide a definitive diagnosis of malignancy. Preoperative 18F-fluorodeoxyglucose-positron emission tomography (18F-FDG-PET/CT) revealed high FDG uptake at the leading edge of the intussusception; however, no findings indicative of metastatic disease were observed. The patient underwent elective surgery, and a right colectomy with lymph node dissection was performed. However, the intussusception was found to have spontaneously resolved at laparotomy. Histopathological examination showed mild intramural congestion in the ileocecal valve. Postoperative imaging confirmed the absence of any lead point lesion, resulting in a final diagnosis of idiopathic intussusception. This case highlights the diagnostic limitations of CT and PET/CT in evaluating lead points in adult intussusception, as false-positive findings are common. Given the possibility of spontaneous resolution, a conservative approach, including repeat imaging immediately before surgery, may be suitable in select cases of adult intussusception.

Adult intussusception commonly has a leading point. In the colon, malignancy is a prevalent etiology for the leading point; however, benign tumors should also be considered. We present a case of colorectal intussusception caused by a giant lipoma. Intussusception in adults is comparatively infrequent in contrast to children, and in adult colonic intussusception, malignancy is the predominant cause of the leading point. Lipoma, an uncommon tumor in the gastrointestinal tract, rarely induces colonic intussusception in adults. We present the case of a 55-year-old Cambodian man experiencing cramping abdominal pain. He presented with mild abdominal distension with tenderness in the lower abdomen. On the rectal examination a large palpable mass was detected three to four centimeters from the anal verge. Abdominal computerized tomography revealed a collapsed sigmoid colon with mesenteric fat invaginated into the lumen of the upper rectum. Emergency laparotomy was performed and during the surgery the sigmoid intussusception spontaneously reduced. A mass was identified in the mid-sigmoid colon, leading to the decision for segmental resection of the sigmoid colon with the mass and subsequent end-to-end anastomosis. Histological examination results confirmed the mass as a lipoma. Colorectal intussusception in adults due to a lipoma is a relatively rare, with only a few reported cases in the literature.

To evaluate the use of ultrasound (US) in the diagnostic work-up of adult intussusception (AI). This multicenter study includes 26 consecutive patients diagnosed with AI between January 2010 and November 2017. A retrospective chart analysis was conducted with a focus on abdominal US findings and diagnostic accuracy of different imaging modalities (ultrasound, computed tomography (CT), magnetic resonance imaging). If available, surgical and pathological findings served as the gold standard (76.9 %). US examiners certified according to DEGUM grade 2 or 3 were classified as experts. Otherwise, they were regarded to have basic skills. During diagnostic work-up, 92.3 % underwent abdominal US. US was the first-line imaging modality in 88.5 % of cases. The accuracy regarding the detection of AI (85 %), correct localization (95 %) and detection of complications (100 %) was excellent and comparable with CT (81 %, 90.5 %, and 91.7 %) when performed by experts. 72.7 % of tumorous lead points were detected by experienced examiners. In contrast, AI was detected in only 45.5 % of cases by examiners with basic skills. AI was diagnosed prior to surgery in all patients. US is reliable in the diagnostic work-up of AI when performed by experienced examiners with high-quality equipment. US, CT and MRI should be used in a complementary fashion since combination provides excellent sensitivity regarding the detection and correct localization of AI as well as the detection of complications. The impact of real-time imaging is illustrated by supplementary videos.