University of Iowa Hospitals and Clinics Iowa City, IA, United States
Asad Ali, MBBS1, Arvind R. Murali, MD2 1University of Iowa Hospitals and Clinics, Iowa City, IA; 2University of Iowa Hospitals & Clinics, Iowa City, IA
Introduction: Intussusception represents the telescoping of a proximal segment of the gastrointestinal (GI) tract (intussusceptum) into the lumen of an adjacent distal segment (intussuscipiens). Malignancy accounts for nearly 65% of all cases of intussusception in adults. These cases are treated surgically as the first line.
Case Description/Methods: An 86-year-old Asian woman with a 2-month history of progressively worsening intermittent diarrhea and 15-Ib weight loss over 4 months. She underwent a colonoscopy which revealed a large polypoid mass with a necrotic area on the surface just proximal to the splenic flexure. The colonoscope was advanced proximally into a narrowed segment beyond the polypoid mass and showed normal colonic mucosa. This raised concern for colonic intussusception (Figure 1a & b). Computed tomography (CT) scan revealed a long segment intussusception involving the cecum and terminal ileum within the transverse colon with the lead intussusceptum terminating near the splenic flexure. There was associated cecal lymphadenopathy concerning for malignancy. There were dilatation and wall thickening of the distal small bowel concerning for early developing obstruction (Figure 2a & 2b).
The patient was taken for emergent laparotomy. Intra-operative findings confirmed an 8 cm cecal mass, acute on chronic intussusception with no signs of distant metastatic disease. She underwent a reduction of the intussuscepted segment, splenic flexure takedown with right hemicolectomy. She was diagnosed with pT3N0M0 (Stage IIA) well-differentiated Cecal Adenocarcinoma and surgery was considered curative. At one-month follow-up, the patient reported a return to baseline functional status. Colonoscopy was performed at 6 months after surgery and was unremarkable.
Discussion: Chronic intussusception is an uncommon endoscopic finding in adults without symptoms of intestinal obstruction. The diagnosis of intussusception is commonly missed or delayed only to be established intraoperatively. The primary treatment option is an intraoperative reduction of the intussuscepted loop and surgical resection of the bowel segment with a lead point. This approach differs from management in children where pneumatic or hydrostatic reduction is the preferred choice. Recognition of endoscopic features of intussusception is crucial for expedited management. Expedited surgical management is important for good outcomes. Attempts to reduce the intussuscepted segments may cause complications like perforation and thus should be avoided.
Figure: Figure 1a & b: A large polypoid mass (intussuscipiens) with ulcerated mass protruding distally into the lumen creating an intussusception.
Figure 2a: A 1.2cm lymph node at the proximal end of the intussuscepted loop. Figure 2b: A cecal mass concerning malignancy.
Asad Ali indicated no relevant financial relationships.
Arvind Murali indicated no relevant financial relationships.
Asad Ali, MBBS1, Arvind R. Murali, MD2. P2790 - Intussusception in an Elderly Woman: A Video Case Report, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.