Intussusception is the most common cause of bowel obstruction in infants and children. Although early recurrence is not uncommon, recurrence years later is rare.
A 13-year-old male with a history of recurrent intussusception at ages 2 and 5 presented with recurrent intussusception 8 years later. The diagnosis was made using computed tomography, and the patient underwent a laparoscopic ileocecectomy with an uneventful postoperative course.
The specimen was remarkable for findings of multiple enlarged lymph nodes over the serosal surface of the ileum and the terminal ileum with focal edema, prominent lymphoid hyperplasia and large hemorrhagic areas.
This case highlights the fact that in a child with a delayed recurrence of intussusception, the presence of a lead point should be suspected, and operative therapy should be strongly considered over hydrostatic reduction. The current management of recurrent intussusception is reviewed and applied to this case.
Intussusception is a rare condition in the adult population. However, in contrast to its presentation in children, an identifiable etiology is found in the majority of cases. Clinical manifestations of adult intussusception are non-specific and patients may present with acute, intermittent or chronic symptoms, predominantly those of intestinal obstruction. A 27-year-old male patient with recurrent abdominal pain secondary to intussusception is herein reported. The clinical presentation and ultrasonographic findings led to the diagnosis. At laparotomy, an ileal hamartoma was found as the lead point of the intussusception. Surgical management and histopathologic studies are described. A recurrent intestinal obstruction and classic ultrasound findings may lead to the diagnosis of intussusception but surgical exploration remains essential. The principle of resection without reduction is well established.
Adult intussusception; Ileum hamartoma; Intestinal obstruction
Intussuception is a rare cause of intestinal obstruction in adults. Diagnosis is often difficult due to the variable and sometimes episodic nature of symptoms. Surgery is the recommended treatment option in adults if the diagnosis is proven.
We present a case of a 33 year old Caucasian female admitted with a small bowel obstruction and no history of previous abdominal surgery. Patient did not improve with medical management consisting of bowel rest and nasogastric tube decompression. Surgery was consulted and patient was taken to the operating room for a laparoscopic-assisted small bowel resection for a small bowel intussusception caused by a submucosal fibroma.
Our case highlights the feasibility and potential benefits of laparoscopy in assisting the diagnosis and treatment of small bowel obstructions.
To describe the sonographic (US) and clinical features of spontaneously reduced small bowel intussusception, and to discuss the management options for small bowel intussusception based on US findings with clinical correlation.
Materials and Methods
During a five years of period, 34 small bowel intussusceptions were diagnosed on US in 32 infants and children. The clinical presentations and imaging findings of the patients were reviewed.
The clinical presentations included abdominal pain or irritability (n = 25), vomiting (n = 5), diarrhea (n = 3), bloody stool (n = 1), and abdominal distension (n = 1), in combination or alone. US showed multi-layered round masses of small (mean, 1.5±0.3 cm) diameters and with thin (mean, 3.5±1 mm) outer rims along the course of the small bowel. The mean length was 1.8±0.5 cm and peristalsis was seen on the video records. There were no visible lead points. The vascular flow signal appeared on color Doppler images in all 21 patients examined. Spontaneous reduction was confirmed by combinations of US (n = 28), small bowel series (n = 6), CT scan (n = 3), and surgical exploration (n = 2). All patients discharged with improved condition.
Typical US findings of the transient small bowel intussusception included 1) small size without wall swelling, 2) short segment, 3) preserved wall motion, and 4) absence of the lead point. Conservative management with US monitoring rather than an immediate operation is recommended for those patient with typical transient small bowel intussusceptions. Atypical US findings or clinical deterioration of the patient with persistent intussusception warrant surgical exploration.
Children, gastrointestinal tract; Intussusception; Intestine, US
A case of recurrent acute retrograde jejunogastric intussusception is described in a 45-year-old man who five years previously had had an antecolic gastrojejunostomy.
Two previous haematemases imply that this complication was recurrent and self reducing an unusual and fortuitous outcome.
Awareness of the possibility of acute intussusception following gastroenterostomy or partial gastrectomy is stressed.
Intussusception is recognized as a common cause of bowel obstruction in small animals. This study documents the clinical and surgical findings in nine cats and 27 dogs diagnosed as having intussusception. The main purposes of the study were to define the predisposing causes and clinical signs of intussusception and to evaluate various surgical techniques commonly employed in its treatment. No common predisposing cause could be established. Diagnosis of intussusception was based most often on clinical signs of bowel obstruction in association with the palpable abdominal mass. The majority of the intussusceptions involved the enterocolic junction. Formation of adhesions was more frequent in cats. Surgical treatments included simple reduction, manual reduction with plication, intestinal resection/anastomosis, and intestinal resection/anastamosis with plication. There was no statistically significant difference (p>0.05) in the recurrence rate of the intussusceptions when the various surgical techniques were compared. Recurrence of an intussusception was not related to either the bowel segment involved or whether a simple reduction, bowel resection, or intestinal plication was performed at the initial surgery.
Localized malignant pleural mesothelioma (LMPM) is a rare occurrence, and gastrointestinal intra-luminal metastases have not previously been reported. Herein, we report a patient with LMPM who presented with a local recurrence 10 mo after initial en bloc surgical resection. Abdominal computed tomography was performed for intractable, vague abdominal pain with episodic vomiting, which showed a “target sign” over the left lower quadrant. Laparotomy revealed several intra-luminal metastatic tumors in the small intestine and colon and a segmental resection of metastatic lesions was performed. Unfortunately, the patient died of sepsis despite successful surgical intervention. Though local recurrence is more frequent in LMPM, the possibility of distant metastasis should not be ignored in patients with non-specific abdominal pain.
Localized malignant pleural mesothelioma; Intussusception; Distant metastasis
Intussusception in adults is uncommon, and it is rare in the descending colon because of its fixation to the retroperitoneum. We herein describe a case of intussusception caused by descending colon cancer. A 74-year-old man was admitted to our hospital for treatment of vomiting and abdominal pain. He had undergone chemotherapy for lymph node recurrence of stomach cancer for about 4 years. Computed tomography revealed a ‘target mass’ with a tumor in the descending colon. We diagnosed his illness as intussusception of a descending colon tumor and performed emergency laparotomy. Conservative resection was performed following anastomosis after reduction of the intussusception. The tumor was pathologically diagnosed as poorly differentiated adenocarcinoma with neuroendocrine features. To the best of our knowledge, this is the first report of an intussusception caused by descending colon cancer incidentally diagnosed during chemotherapy for stomach cancer recurrence.
Intussusception; Descending colon cancer; Stomach cancer recurrence; Chemotherapy
A case of recurrent acute jejuno-jejunal intussusception presenting in the post operative period of the surgery for acute ileocolic intussusception is presented. Post operative intussusception is defined as intussusception occurring within 30 days of the primary surgery . This is a rare entity. Jejuno-jejunal intussusception is also rare. Recurrent intussusception is uncommon. The present case is a combination of all these rarities.
Recurrent intussusception; Jejuno-jejunal intussusception; Post operative intussusception
Blue rubber bleb naevus syndrome (BRBNS), is an uncommon condition characterised by cavernous haemangiomas of skin and gastrointestinal tract. The most common complication of this syndrome is gastrointestinal bleeding. Intussusception of bowel, although a known complication, has rarely been reported.
We report the case of a 37-year-old man who presented with multiple intussusceptions of small bowel. He required an urgent laparotomy and bowel resections. He suffered from BRBNS. This is the first reported case of multiple synchronous intussusceptions affecting both jejunum and ileum, secondary to haemangiomas occurring in an adult with BRBNS. The underlying conditions of acute abdomen in patients with BRBNS may include intramural haemorrhage, infarction, volvulus or intussusception of bowel. Treatment options include pharmacological manipulation, bowel resection, and interventions such as sclerotherapy, angiographic embolisation, endoscopic ligation, electrocautery and laser photocoagulation for visceral lesions.
A high index of suspicion is required whilst dealing with acute abdomen in patients with BRBNS. Clinical trials may provide some answers as to the preference of treatment in individual cases, as the current level of evidence does not offer a clear choice of optimal treatment.
Intussusception (IS) is a common cause of bowel obstruction in the pediatric population. Traditionally, unsuccessful hydrostatic reduction has been followed by laparotomy. With the advent of minimally invasive surgery, centers have adopted laparoscopic reduction as a surgical option. We reviewed our experience with IS and investigated whether there were any advantages to performing laparoscopy over conventional laparotomy in unsuccessful air enema reduction (AE).
All the records of patients admitted from January 2001 to August 2004 with a diagnosis of IS (diagnosis code 560.0) were reviewed. Parameters investigated included age, sex, weight, radiological intervention, operative procedure, length of stay (LOS), and days to oral intake (PO). Statistical analysis was performed with the 2-tailed t test to compare outcomes and Fisher's exact test to assess differences in nominal frequencies.
Seventeen males and 9 females diagnosed with IS were identified. The mean age was 2.5 years (range, 1 month to 14 years), and the average weight was 5.65 kg (range, 4.65 to 95). Twenty-three of the 26 patients (88.5%) underwent AE reduction, with success in 13 (57%). One recurred after initial successful AE, 9 failed multiple attempts at AE, and 2 attempted reductions were complicated by perforations. Fifteen patients underwent surgical reduction for unsuccessful AE or to address a pathological lead point. The success rate of laparoscopic reduction was 85%. The average time to resumption of PO intake for patients with successful AE was 0.5 days, and after laparoscopic reduction, the average time to PO intake was 1.5 days, while it was 4 days after laparotomy (P=0.05). After laparoscopic reduction, the average LOS was 6 days, but LOS was 7 days after laparotomy (P=0.66)
Many children who present with IS can be treated by AE. In patients who fail AE, laparoscopy offers a safe, effective alternative to laparotomy.
Laparoscopy; Laparotomy; Intussusception; Air enema reduction
Adult intussusception is uncommon and requires a surgical approach. Malignancy is associated with 31% (43/137) of small bowel intussusception and 70% (74/106) of large bowel intussusception. Computerized tomography (CT) findings are pathognomonic for this condition. Often, the patient presents with long-standing, nonspecific complaints. A 63-year-old man presented with sudden onset of abdominal pain. CT demonstrated colonic inflammation. A laparoscopic right hemicolectomy for ileocecal intussusception was performed. The pathology report revealed a lipoma of the cecum. The postoperative course was uneventful, and he was discharged the fifth postoperative day. Despite a high incidence of malignancy, colonic or ileocecal intussusception can be successfully treated by laparoscopic resection. Review of the literature and treatment options are discussed.
Laparoscopic hemicolectomy; Ileocecal; Adult intussusception
Background and objective:
With the advent of laparoscopy into pediatric surgical filed and with experience gaining, as well as, improvement in instrumentation, it has been used in management of different conditions, including intussusception. However, there is no universal acceptance regarding its role in reduction of intussusception. This is due to the early reports of high conversion rate and the concern of missing a lead point. The aim of this article is to review the literatures about safety and efficacy of laparoscopy in intussusception management and the limitations as well as formulating a working algorithm for management of intussusceptions in pediatric age group up to 18 years. Up to my knowledge this is the first review article in this subject.
A comprehensive review of the English literature in Pub Med searching engine was conducted with key words laparoscopy, intussusception, management of intussusception, minimal invasive surgery and intussusception, laparoscopic reduction of intussusception, between 1996 and2009 .The results yielded were further explored for citation regarding the role of laparoscopy in reduction of intussusception.
The success rate increased from 57% in 1997 to 91% in 2009 while the conversion rate decreased from 43% in 1997 to 9% in 2009.The presence of a lead point and/or ischemic bowel were the main reasons for conversion in the initial reports.
Laparoscopy is a safe and efficient method for reduction of intussusception. The presence of a lead point or necrotic bowel is no more indication for conversion to open surgery. Laparoscopy should be an integral tool in the management algorithm of intussusception.
intussusception reduction; laparoscopy in children; role of laparoscopy in intussusception
The hospital records of 111 children aged 2 to 15 years who were treated for intussusception between mid-1974 and mid-1984 were reviewed. Severe intermittent abdominal pain was the most consistent, and frequently the only, clinical feature. Hydrostatic reduction was almost as successful as in children under 2 years of age, and its success was independent of the duration of symptoms. Most cases were idiopathic, but lead points were common in children 6 years of age or older. There was an unexpectedly high recurrence rate, 20%. In all three children with lymphoma the signs and symptoms were clearly atypical and were suggestive of pre-existing disease. In the absence of suspicious clinical or radiologic findings, laparotomy to rule out lymphoma is not warranted.
A case of recurrent intussusception in a 76 year old man associated with vascular proliferation is reported. The initial biopsy specimen showed that ulceration and inflammation were not features. The proliferation was so florid as to point to an angiomatous lesion. At this stage a diagnosis of intussusception was not considered. The clinical impression was that of a caecal mass associated with a filling defect visible on barium enema and a fleshy "suspicious" lesion on colonoscopy. This case illustrates the possibility of misinterpreting the importance of florid vascular proliferation in biopsy material where other features indicative of a reparative process are absent.
Despite its common association with viral illnesses,
intussusception has only rarely been found in the presence of bacterial infections. Two infants are described, both of whom were admitted to
hospital with bilious vomiting, drowsiness, and dehydration. Both
infants required urgent intravenous volume expansion. Intussusception was confirmed, and reduction was achieved by enema in both cases. Recovery was slow, and one infant developed a seizure. Evidence of
meningococcal meningitis was found in both, with septicaemia in one.
Neurological outcome is normal to date, and there has been no
recurrence of intussusception in either case.
Abdominal pain is a frequent symptom in the child with Henoch-Schönlein purpura and raises the suspicion of intussusception or perforation. One hundred and fifty two children with a diagnosis of Henoch-Schönlein purpura over 11 years were reviewed. Of these 60 had abdominal pain, 19 gastrointestinal bleeding, and nine were suspected intussusception. Intussusception was confirmed in two of these cases with ultrasonography. Ultrasound is an important tool in the early diagnosis of intussusception complicating Henoch-Schönlein purpura. Where the intussusception appears loose an expectant policy, with careful monitoring, may allow spontaneous reduction. It may also be used in monitoring patients for postoperative recurrence of intussusception, mural haematoma, and uncomplicated intestinal vasculitis with oedema.
A case of recurrent colo-colic intussusception due to a primary colloid carcinoma of descending colon with widespread lymphatic involvement in a child, is reported. The unusual mode of presentation and lack of awareness were responsible for a delay of 6 months before the final diagnosis was made. Two years after the operation the patient is well and there is no evidence of clinically detectable secondaries.
Barium enema reductions were attempted in 65 (90%) of 72 intussusceptions, of which 51 (79%) were successful. This represents a success rate of 70% overall. The average hospital stay was 3 1/2 days. There was no mortality and, apart from a recurrence rate of 10%, no morbidity. It is suggested that barium enema reduction should be the treatment of choice provided that there is an emergency service of a paediatric radiologist and the patient is adequately resuscitated, the only absolute contraindication being evidence of pneumatosis intestinalis or peritonitis. Those patients who presented with shock, rectal bleeding, duration of symptoms longer than 48 hours, and pronounced degree of bowel obstruction had a higher rate of unsuccessful reduction. However, only the last two were significant. Further, provided that the clinical condition remains satisfactory and the reduction has been achieved to the caecum a repeat barium enema after some hours may be successful in achieving reflux of contrast into the ileum, confirming complete reduction.
Eosinophilic gastroenteritis is defined as a disorder that selectively affects the gastrointestinal tract with eosinophil-rich inflammation in the absence of any known causes for eosinophilia. The clinical manifestations vary according to the site of the eosinophilic infiltrated layer of the bowel wall. Eosinophilic enteritis presenting as intussusception in adult has not been previously reported in the literature. Especially, making the diagnosis of intussusception in adults is often difficult due to the variable clinical findings. In our case, the correct diagnosis of intussusception due to eosinophilic enteritis was arrived at rather easily based on the ultrasonography and endoscopic biopsy. The patient was treated with oral prednisolone at 30 mg/day for 7 days, and then the drug was tapered off for 2 months; we didn't perform surgery. He has been asymptomatic for about 1 year after discharge without disease recurrence.
Eosinophils; Enteritis; Intussusception; Steroids
Lipoma and angiolipoma are common benign neoplasms that occur in the subcutaneous tissue and rarely in the gastrointestinal tract. These tumors are usually asymptomatic but may present with abdominal pain, bleeding and obstruction. We present a 53-years-old woman with abdominal discomfort for several weeks accompanied with bloody diarrhea and recurrent vomiting. Ileo-ileal invagination was diagnosed by computed tomography scan. Laparotomy revealed five intraluminal masses that caused intussusception. Histopathological study showed that one was angiolipoma and other lesions were lipoma. We have described some aspects of diagnosis and treatment of this rare cause of intestinal intussusception.
Peutz-Jegher’s syndrome is a rare autosomal dominant disorder that typically manifests itself as recurrent colicky abdominal pain and blood loss in stools. In adults, it is only rarely accompanied by frank intussusception and intestinal obstruction. We encountered an adult Asian Indian male who presented with an intestinal obstruction due to jejunoileal intussusception. It was caused by a 3.5 cm large hamartomatous polyp of Peutz-Jegher’s syndrome. We feel reporting the unusual presentation of this rare condition may be a noteworthy contribution to the scarce literature on Peutz-Jegher’s syndrome from India. The case report may be of educational importance to the clinicians and students because it is unusual to see this case in typical clinical practice.
A 38-year-old Asian Indian male presented to us in the surgical emergency room with colicky abdominal pain, reporting vomiting and blood in stools over the previous two days. Clinical examination suggested intestinal obstruction. Ultrasonography of the abdomen showed signs of intussusceptions, which were then confirmed by an emergency exploratory laparotomy. We resected the intussuscepted small bowel segment and performed a jejuno-ileal anastomosis. A histopathology examination of the resected specimen revealed multiple hamartomatous polyps suggestive of Peutz-Jegher’s syndrome. In this case report, we present the pathology findings, their clinical correlation and a detailed discussion of Peutz-Jegher’s syndrome and adult intussusception. We also discuss its other rare presentations reported in literature.
Hamartomatous polyps of Peutz-Jegher’s syndrome can sometimes grow to a large size and form the lead point of an intussusception.
Adult intussusception is rare and most often associated with cancer. We report a case of intussuscepted sigmoid colon into the rectum protruding from the anus of a 47-year-old woman. The cause of the intussusception was sigmoid colon cancer. We removed the intussuscepted part of the sigmoid colon as well as the rectum and regional lymph nodes. The patient recovered uneventfully and there has been no evidence of recurrence of the cancer.
Adult intussusception; Sigmoid colon cancer; Surgery
Colocolonic intussusception is an uncommon cause of intestinal obstruction in children. The most common type is idiopathic ileocolic intussusception. However, pathologic lead points occur approximately in 5% of cases. In pediatric patients, Meckel’s diverticulum is the most common lead point, followed by polyps and duplication. We present a case of recurrent colocolonic intussusception which caused colonic obstruction in a 10-year-old boy. A barium enema revealed a large polypoid mass at the transverse colon. Colonoscopy showed a colonic polyp, 3.5 centimeters in diameter, which was successfully removed by endoscopic polypectomy.
Colocolonic intussusception; Juvenile polyp; Endoscopic treatment; Large colonic polyp
The “Chinese Fan Spread” (CFS) distraction technique for laparoscopic reduction of intussusception is herein described and its outcome and benefits are evaluated.
A retrospective review was performed of all patients who underwent attempts at laparoscopic reduction of intussusception at our center. The CFS distraction technique was consistently applied in all cases.
Fourteen patients were identified. Median age was 2.4 years (range, 4 months to 10.3 years). Indications for surgery included (1) failed pneumatic reduction (n=11), (2) need to evaluate for lead point in a patient with 4 recurrences (n=1), (3) need to biopsy the lead point in a patient with suspected lymphoma (n=1), and (4) diagnostic laparoscopy for evaluation of hematochezia (n=1). Two patients who failed laparoscopic reduction by the CFS distraction technique also failed open manual reduction, requiring right hemicolectomy. Of the 12 (86%) who were successfully reduced laparoscopically, pathologic lead points were identified in 5 (2 acute appendicitis, 1 Meckel's diverticulum, 1 harmatomatous polyp, and 1 Burkitt's lymphoma). Lead points were excised laparoscopically or via a vertical transumbilical incision. There were no complications.
Laparoscopic reduction of intussusception by the CFS distraction technique is effective and safe. Lead points may be dealt with together either laparoscopically or via a transumbilical incision.
Laparoscopic reduction of intussusception; Children; Chinese fan spread