To the editor: Intestinal invagination is uncommon in adults, and neoplasm is the main cause. Ileo-ileal invagination due to lymphoma in adults has been rarely reported in the literature. A 18-year-old man was admitted to our clinic with complaints of abdominal pain, vomiting, obstipation and fever. Two months ago he had been sent to a town hospital because of pain in the right lower quadrant, vomiting and fever and he had been operated on after a diagnosis of acute appendicitis. Since his symptoms had continued in the first week postoperatively, the patient had been re-operated on with draining of periappendicular abscess. Because of his deteriorating condition after operation, he was referred to our hospital. On admission vital signs were normal other than fever (38°C). He was cachectic and abdominal distension with diffuse tenderness was present. Bowel sounds were silent on auscultation and digital rectal examination showed nothing abnormal. Laboratory studies revealed white blood cell count, 24 000/mm3; hemoglobin, 11.4 g/dl; platelets, 171 000/mm3; urea, 47 mg/dl (10–50 mg/dl); creatinine, 1.15 mg/dl (0.5–1.2 mg/dl); alanine aminotransferase, 21 U/L (0–40 U/L); aspartate aminotransferase, 18 U/L (0–40 U/L); alkaline phosphatase, 345 U/L (38–155 U/L); gamma-glutamyltransferase, 93 U/L (15–60 U/L); total bilirubin, 0.3 mg/dl (0.1–2.0 mg/dl); direct bilirubin, 0.1 mg/dl (0.1–0.8 mg/dl); albumin, 3.2 g/dl (3.5–5.0 g/dl); globulin, 2.3 g/dl (2.3–3.5 g/dl); amylase, 297 U/L (28–100 U/L); sodium, 139 mmol/L (132–146 mmol/L); potassium, 3.9 mmol/L (3.3–5.4 mmol/L); calcium, 2.26 mmol/L (2.15–2.55 mmol/L); CRP, 15 mg/dl (0–5 mg/dl); and erythrocyte sedimentation rate, 74 mm/h. An abdominal ultrasonography revealed dilated intestinal loops with fluid between them. Abdominal computerized tomography showed two hypoechoic lesions in liver, eudematous mesenterium, and concentrically thickened bowel loop with a mass of fatty density inside (Fig.).Fig.: Abdominal tomography showing concentrically thickened bowel loop demonstrating intestinal invagination.The patient was re-operated on immediately after the diagnosis of intestinal invagination. During the operation, invagination was observed, and right hemicolectomy, resection of the distal ileum, distal ileostomy, and wedge resection from the liver were performed. Histological examination showed marked lymphocytic infiltration in the whole small intestinal wall, muscularis mucosa and serosa of the large intestine, mesentery, liver, and lymph nodes. Immunohistochemistry showed CD3 (-), CD5 (-), CD10 (-), CD20 (+), CD45 (+) malignant B cell lymphoma. A month later the patient was painless without complaints of the ileus. He was referred to medical oncology department and died after the first course of chemotheraphy. Intestinal invagination, a common cause of intestinal obstruction in pediatric population accounts for about 5% of cases in adults.1 Although there is a rare anatomic abnormality in children, invagination is associated with an underlying pathologic process in more than 90% of cases in adults.1,2 In contrast to the large intestine, benign lesions including hamartomas, lipomas, imflammotory polyps, adenomas, and leiomyomas predominate in the small intestine. In the large intestine, malignant changes (usually adenocarcinomas) are the most common causes. Invagination may be colo-colic, entero-colic or entero-enteric. Lesions causing invagination are generally located in the small intestine with or without progressive involvement of the colon, and colic lesions are less common and can determine isolated colocolic forms or drag the ileum to form ileocecocolic invagination.3 Although there are several reports regarding ileo-ileal invagination in the literature, to our knowledge, such an invagination due to lymphoma in an adult has been reported only once.4 Adults with invagination usually present with partial intestinal obstruction and preoperative diagnosis of ileo-ileal invagination may be troublesome as in our patient. Sonography and computerized tomography are the most effective preoperative diagnostic methods. In adults, since it is difficult to diagnose invagination of the small intestine or malignancy is suspected, surgery should be the diagnostic and therapeutic procedure. Although wide resection including hemicolectomy is advocated for colonic and ileo-colonic invagination, size of the resection for ileo-ileal invagination is not clear. Ömer Başar Bülent Ödemiş Íbrahim Ertuğrul Hilmi Ataseven Taner Oruğ Department of Gastrosurgery, Türkiye Yüksek íhtisas Hospital, Tepebaşi Mahallesi, Fatih caddesi, No: 181/12, 06290, KeçiÖren, Ankara, Turkey (Tel: 90–312–3808161. Fax: 90–312–3124120. Email: [email protected])
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Mar 1, 2008
Christian Donato‐Santana + 2
Open Access
