This 67-year-old lady initially presented to her general practitioner (GP) 3 years previously with intermittent generalised abdominal pain associated with diarrhoea. She had no significant medical history but did have an extensive surgical history having undergone a partial gastrectomy for gastric ulcer (1973), a total abdominal hysterectomy with bilateral salpingo-oophrectomy (1995), an open cholecystectomy (1998) and right breast lumpectomy for breast cancer (2000). This patient was an ex-smoker and there was no family history of note. Clinical examination revealed a slim lady with evidence of previous abdominal surgery, but no specific cause for the pain. Investigations organised by the GP, including a CT scan of the abdomen and pelvis, were normal and she was given a diagnosis of irritable bowel syndrome. Over the next 3 years her abdominal pain persisted, becoming more severe and was now associated with weight loss, however, there were no symptoms of vomiting or complete constipation. Referral to a colorectal surgeon was made. Full blood count, urea and electrolytes and liver function tests were unremarkable but a CT scan revealed features consistent with a small bowel intussusception (). A barium enema follow-through also demonstrated an intussusception in the proximal jejunum.
CT scan showing radiological evidence of small bowel intussusception seen as a ‘target lesion’ (arrow), that is, lumen-within-lumen.
A capsule endoscopy showed an inflamed segment of small bowel and it was postulated that repeated episodes of intussusception could have caused such an appearance. As a result of these investigations an elective laparotomy was performed 6 weeks later. At surgery, a single adhesional band from the small bowel mesentery to the right iliac fossa was found. The rest of the contents of the peritoneal cavity were examined carefully for any signs of abnormality, including systematic palpation and visual inspection of the small bowel and no evidence of intussusception either past or present could be elicited. In particular there was no mass in the small bowel. It was assumed that the CT appearances were artefactual and that in fact the small bowel was becoming obstructed intermittently due to volvulus around the band and the adhesion was therefore divided. She made an uneventful postoperative recovery and was discharged home on postoperative day 5 tolerating small amounts of food and drink and passing flatus.
The patient was re-admitted to the surgical assessment unit 3 days later (day 8 postoperative) with constant upper abdominal discomfort and fullness associated with several episodes of vomiting. She had opened her bowels for the first time since her laparotomy just the day before but only small amounts. Again haematology tests were unremarkable and abdominal plain radiograph demonstrated a single dilated small bowel loop (4.5 cm) in left lower quadrant ().
Plain abdominal film on re-admission to surgical assessment unit 8 days postoperatively showing a dilated loop of small bowel consistent with obstruction (arrow).
The impression at this stage was that of subacute small bowel obstruction secondary to further adhesions or a prolonged ileus and so the plan was to manage her conservatively. Four days following admission she was tolerating oral fluids but vomiting with light diet. An abdominal CT scan was performed as she failed to settle which reported a 13 cm intussusception in the distal small bowel ().
CT scan on readmission showing recurrent small bowel intussusception (arrow).