A 13-year-old child was admitted in the emergency ward of the Department of General Surgery, Safdarjung Hospital, with complaints of abdominal pain for 15 days and repeated episodes of vomiting and passing blood in the faeces with abdominal distension for 7 days and obstipation for the previous day. The pain was initially colicky in nature more so on the left lower quadrant of the abdomen but at a later date progressed to being continuous. Initially the pain was accompanied by gradual distension of the abdomen followed by vomiting. There was history of passage of worms per rectum 1 month back associated with low-grade fever. There were no bladder complaints, jaundice, weight loss, similar episodes previously, tuberculosis, or exposure to tuberculosis. The patient had underwent left-sided orchidopexy for undescended testis at 3 years of age.
Physical examination showed distended abdomen and tenderness in the left iliac fossa. No separate lump was palpable. Digital rectal examination revealed red currant jelly stools, and anal canal was found to be ballooned. Bowel sounds were absent. The rest of the systemic examination was found to be unremarkable. Among the blood investigations, hemogram, kidney, and liver function tests, serum electrolytes were found to be within normal range. The erect abdominal X-rays revealed dilated large bowel loops signifying distal intestinal obstruction (). The ultrasound of the abdomen showed mild splenomegaly (12.5
mm right renal calculus in the middle calyx with no hydronephrosis, and mild interbowel-free fluid with no signs suggestive of intussusception. Based on these preoperative clinicoradiological findings, a diagnosis of large bowel obstruction was made, and decision was taken to perform a laparotomy.
Erect abdominal X-ray showing dilated large bowel loops.
The laparotomy was undertaken using the midline incision, and the following findings were noted:
- small bowel collapsed, ileocecal junction was found to be normal;
- descending colon-sigmoid colon intussusception with a 3cm × 3cm intraluminal polypoidal growth in the descending colon acting as the lead point, with the sigmoid colon as the intussuscipiens ().
Photograph showing the colocolic intussusception.
The intussusception was reduced manually (), and segmental resection was done taking 5
cm margins on either side (). Colo-colic anastomosis was performed in double layers, and a protective loop ileostomy was created 1 and 1/2 feet proximal to the ileo-cecal junction. The specimen was subjected to histopathological examination.
Intussusception being reduced intra-operatively.
Resected specimen showing the polypoid growth with irregular luminal surface in the descending colon.
Postoperatively the patient was allowed oral clear fluids on the first postoperative day and semisolid diet on the second postoperative day. The patient was discharged on the fourth postoperative day.
The histopathological examination of the resected specimen diagnosed it to be mucinous adenocarcinoma of the colon with the resected margins microscopically free from the tumor. The patient in the followup period underwent contrast enhanced CT scan of the abdomen, pelvis and thorax, CEA levels, and colonoscopy to look for synchronous lesions, all were found to be normal, and the child was thereafter referred to the Medical Oncology and Radiation Oncology Department where he is being considered for adjuvant therapy and is under fortnightly follow-up.