Introduction: Due to the duodenum’s fixed retroperitoneal positioning, duodeno-duodenal intussusception is considered impossible, except in the cases of malrotational abnormalities. In the case presented, we note the rare presentation of adult duodeno-duodenal intussusception secondary to an ulcer in the descending portion of the duodenum into an adjacent diverticulum.
Case Description/Methods: A 73-year-old Caucasian female presented to our emergency department with a 24-hour history of acute abdominal pain. Vital signs on admission were unremarkable and abdominal examination revealed significant tenderness of the upper abdomen, greater on the right than left. Lab findings were notable for an elevated white blood cell count of 14.5 x 103/μL. Abdominal and pelvic computed tomography (CT) with contrast revealed intussusception of the descending duodenum extending into a duodenal diverticulum. General surgery evaluated the patient and recommended an esophagogastroduodenoscopy (EGD) to evaluate for a mass or tumor and to determine if the patient required surgical intervention. The EGD demonstrated a duodenal ulcer with edema without any signs of a mass. After conservative management and clinical resolution, patient was discharged home.
Discussion: Although, abdominal CT is considered the most reliable investigation in making a preoperative diagnosis, most patients who present with adult intussusception should be evaluated with an EGD to rule out a malignancy. CT can detect the characteristic features including a "target" or "sausage" shaped soft tissue mass with a layering effect of the inner and outer intussuscipiens and the mesentery and/or omentum. Unfortunately, this layering effect can be difficult to distinguish from mucosal prolapse potentially leading to misdiagnosis. Despite this possibility, when intussusception is secondary to a lead point, abdominal CT has been shown to distinguish signs of bowel obstruction, bowel wall edema as well as a loss of the classic 3-layer appearance due to impaired mesenteric circulation.
Regardless of the cause, an EGD can prove to be diagnostic and/or therapeutic; potentially reducing the intussusception by insufflation and dilatation of the stomach and duodenum. Ultimately, surgical resection is usually required but in rare cases such as the one discussed above when malignancy, ischemic necrosis or intestinal perforation are ruled out, a simple reduction should suffice.
Figure: Figure 1 A. Coronal View of CT Abdomen and Pelvis with contrast showing a target sign (red circle) B. Sagittal View of CT Abdomen and Pelvis with contrast showing duodenal intussusception into diverticulum (red arrow) C. EGD showing ulcer in descending duodenum with surrounding erythema
Disclosures: Sean-Patrick Prince indicated no relevant financial relationships. Sabrina Urs indicated no relevant financial relationships. Andrew Santos indicated no relevant financial relationships. Anil Ram indicated no relevant financial relationships. Siddharth Mathur indicated no relevant financial relationships.
Sean-Patrick Prince, MD, MPH, Sabrina Urs, MD, Andrew Santos, MD, Anil Ram, MD, Siddharth Mathur, MD. P0949 - Adult Duodeno-Duodenal Intussusception into a Diverticulum Secondary to a Duodenal Ulcer, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
.jpg "Sean-Patrick A. Prince, MD, MPH photo")
