Intussusception in the adult: a rare cause of mechanical obstruction

Revista de Gastroenterología de México. 2012;77(3):153-156
CLINICAL CASE
Intussusception in the adult: a rare cause of mechanical
obstruction
R. Franco-Herrera*, M. Burneo-Esteves, J. Martín-Gil, A. Fabregues-Olea, D. Pérez-Díaz
and F. Turégano-Fuentes
Department of General Surgery and the Digestive Tract II. Hospital General Universitario Gregorio Marañón. Madrid, Spain
Received 16 November 2011; accepted 9 April 2012
Available online 24 August 2012
Keywords
Intussusception;
Lipoma; Melanoma;
Small Bowel; Spain.
Abstract
Intussusception is an infrequent cause of mechanical intestinal obstruction in the
adult. We present herein 2 clinical cases of intussusception with different etiologies. In the first
case, the underlying cause was a lipoma, and in the second, it was metastasis from melanoma.
In both cases the intussusception was identified through computed tomography and treatment
was intestinal resection. Pathologic anatomy provided the definitive diagnosis. Etiology is diverse and it is more common for obstruction to be due to organic lesions that are malignant at the
level of the colon and benign at the level of the small bowel. Currently there are more preoperative diagnoses thanks to the advances made in imaging study techniques. Intestinal resection
continues to be the treatment of choice in the majority of cases, because of the high percentage of malignant lesions as the underlying cause.
© 2011 Asociación Mexican de Gastroenterología. Published by Masson Doyma México S.A. All
rights reserved.
PALABRAS CLAVE
Invaginación
intestinal;
Lipoma;
Melanoma;
Intestino delgado
Invaginación intestinal en el adulto. Una causa infrecuente de obstrucción mecánica
Resumen La invaginación intestinal constituye una causa poco frecuente de obstrucción mecánica del adulto. Presentamos 2 casos clínicos de invaginación intestinal con diferentes etiologías, en el primer caso la causa subyacente fue un lipoma, mientras que en el segundo fue una
metástasis de melanoma. En ambos, la tomografía computada identificó la intususcepción y el
tratamiento fue una resección intestinal. La anatomía patológica nos proporcionó el diagnóstico
definitivo. La etiología es diversa, siendo más frecuente que la obstrucción se corresponda con
lesiones orgánicas malignas a nivel de colon, y benignas en intestino delgado.
*Corresponding author: Tomás López número 12 2H C.P. 28009, Madrid, Spain.
Telephone: +661288000.
Email: [email protected] (R. Franco-Herrera).
0375-0906/$ – see front matter © 2011 Asociación Mexicana de Gastroenterología. Publicado por Masson Doyma México S.A. Todos los derechos reservados.
http://dx.doi.org/10.1016/j.rgmx.2012.04.007
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R. Franco-Herrera et al
El diagnóstico preoperatorio ha aumentado actualmente, gracias al avance de las pruebas de
imagen. La resección intestinal sigue siendo el tratamiento en la mayoría de las ocasiones, por
el alto porcentaje en el que una lesión maligna es la causa subyacente.
© 2011 Asociación Mexicana de Gastroenterología. Publicado por Masson Doyma México S.A.
Todos los derechos reservados.
Introduction
Case presentation
the jejunal segment encompassing both tumors and manual
biplane side-to-side jejunojejunal anastomosis were performed. Postoperative ileus was resolved with conservative
treatment and the patient was released from the hospital
on the ninth day after surgery.
Anatomopathologic study reported the presence of intestinal metastases from a malignant melanoma with mesentery involvement, and vascular and lymph node infiltration
with 2 large nodes, one of which was intraluminal. After
evaluation by our institution’s tumor committee, palliative
treatment was decided upon.
Case 1
Case 2
The patient is an 81-year-old man with a past medical history of chronic obstructive pulmonary disease, high blood
pressure, myelodysplastic syndrome and anemia, who was
operated on for cervical melanoma and underwent right
pulmonary lobectomy for unknown causes. Clinical presentation only manifested as intermittent abdominal pain. In
order to evaluate his anemia, upper gastrointestinal (GI) endoscopy and colonoscopy were carried out, both of which
were normal. An abdominal computed tomography (CT)
scan was taken that showed a jejunojejunal invagination
with a large tumor and voluminous adjacent adenopathy
(fig. 1).
The patient was programmed for surgery and a jejunojejunal invagination conditioned by a tumor of 6 cm in diameter with proximal dilatation and an adjacent necrotic
mass of 7 cm in diameter were found (fig. 2). Resection of
A 45-year-old woman with a past medical history of surgery
for urinary incontinence came to the emergency room complaining of hypogastric abdominal pain and bloody stools,
with no other accompanying symptoms. Physical examination revealed a soft and depressible abdomen, with abdominal guarding upon palpation of the left middle abdomen and
hypogastrium, and intense pain that did not cease with
nonsteroidal anti-inflammatory agents or rescue drugs with
morphine. A CT scan identified a 20 cm colocolic invagination (transverse colon and splenic angle of the descending
colon) (fig.3), probably secondary to a well-differentiated
fatty tumor, with no radiologic signs of occlusion or other
complications.
Surgical intervention revealed an invagination at the level
of the left sigmoid colon and part of the transverse colon
(fig. 4) and a 12 cm partially necrotized tumor in the sigmoid colon with an extramucosal appearance for which left
The introduction of one segment of intestine inside another
through the action of peristalsis is a very infrequent cause
of mechanical bowel obstruction in the adult. Organic processes are the habitual causes1-8. In this report, 2 cases are
presented of intestinal intussusception due to 2 uncommon
causes: lipoma and metastatic melanoma in the small
bowel.
Figure 1 Cross-sectional view of the abdominopelvic CT scan
showing the invagination of an intestinal segment into the
opening of the adjacent intestine. Jejunojejunal invagination.
Figure 2 Surgical specimen showing the jejunojejunal invagination
and the adjacent necrotic mass.
Intussusception in the adult: a rare cause of mechanical obstruction Figure 3 Longitudinal view of the abdominopelvic CT scan
showing the characteristic “sausage” image of the intestinal
invagination.
hemicolectomy was performed. The anatomopathologic study reported submucosal lipoma with findings compatible
with acute intussusception (apical necrosis, parietal edema
in adjacent zones) and fibrosis and mural hypervascularization
phenomena compatible with chronic ischemia.
Discussion
Intestinal invagination is an exceptional cause of mechanical bowel obstruction in the adult, contrary to what takes
place during childhood. A lesion on the intestinal wall that
155
produces an alteration in peristalsis causes a proximal segment to be introduced into a distal one; when this involves
the mesenterium it gives rise to vascular compression, edema of the wall, and necrosis of the segment if not treated
opportunely. Etiology is diverse and is idiopathic in 10,0% of
cases. The underlying cause in 70,0% to 90,0%1 of cases is an
organic lesion of malignant origin, more frequently at the
level of the colon. In the small bowel its origin is benign
(lipomas, hamartomas, neurofibromas, leiomyomas, inflammatory adenomas)2. Other less frequent causes are Meckel’s
diverticulum, or adherences, or hematoma of the wall8. Clinical presentation is nonspecific and can be chronic or acute. Its signs and symptoms are bowel obstruction, colicky
abdominal pain, abdominal bloating, the absence of transit,
nausea, and vomiting. The presence of melena or rectal
bleeding usually indicates a malignant tumor.
Contrary to what occurred in case series in the past,
preoperative diagnosis3 is currently on the rise. Abdominal
ultrasound showed a target image in the cross-sectional
view and multiple thin, parallel, hypoechoic, and echogenic
layers in the longitudinal view. This method has a 100,0%
sensitivity and an 88,0% specificity4, and is often a good way
to begin the diagnostic series, especially in locales with limited resources. In the barium transit study we could observe a filling defect. Abdominopelvic CT scan with oral
contrast material evaluates etiology, and in the case of a
malignant tumor, locoregional involvement or distant metastasis. Colonoscopy and sigmoidoscopy can be useful in
processes at the level of the colon. Despite all these diagnostic studies, in many cases diagnosis continues to be intraoperative5,10. In regard to treatment, intestinal resection
is currently the norm, due to the increased probability of
malignant underlying lesion, especially in the elderly patient 6,10. At present there is no evidence to contraindicate
invagination reduction, because it facilitates exposure for
resection in virtually all cases. The laparoscopic approach
could possibly be an option in cases in which surgery can be
deferred and planned3. Furthermore, it would be interesting
to consider the treatment of the underlying cause that presents in any given case.
When the patient described in clinical case 1 arrived at
our hospital, he presented with stage IV disease. Gastrointestinal metastases from melanoma are a reflection of advanced stage disease and therefore treatment should be
mainly palliative. Surgery is very effective for reducing
symptoms (80,0% to 90,0%) and improving quality of life in
these patients9. Today, not all patients with metastatic melanoma are incurable, as was the case in the past. Drugs
such as vemurafenib, used in molecularly directed therapy, and ipilimumab, used in immunotherapy, offer new and
valuable options for a disease that has lacked effective
treatments11.
Financial disclosure
No financial support was received in relation to this article.
Figure 4 Image of the resection specimen showing the colocolic
invagination.
Conflict of Interest
The authors declare that there is no conflict of interest.
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