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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 2  |  Issue : 3  |  Page : 96-98

Small bowel adenocarcinoma masquerading as ileocolic intussusception


Department of Surgical Gastroenterology and Hepatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Date of Submission05-Feb-2022
Date of Decision18-Mar-2022
Date of Acceptance15-May-2022
Date of Web Publication05-Jul-2022

Correspondence Address:
Abilash Krishna Prasad
14/124, Krishnaabhilasham, Calicut Coimbatore Bypass Road, Kalpathy P.O., Palakkad - 678 003, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ghep.ghep_6_22

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  Abstract 


Compound intussusception in the form of ileocolocolic intussusception is rare. Here we present a case of a 83 year old man who presented with abdominal pain, failed colonoscopic reduction and underwent laparotomy with resection and anastomosis. Postoperative course was uncomplicated. The final biopsy showed features of moderately differentiated adenocarcinoma of ileum.

Keywords: Compound intussusception, ileocolocolic intussusception, intussusception, small bowel adenocarcinoma


How to cite this article:
Prasad AK, Varanasi B, Rajendran U, Dcruze L, Subramanian S, Venkataraman J. Small bowel adenocarcinoma masquerading as ileocolic intussusception. Gastroenterol Hepatol Endosc Pract 2022;2:96-8

How to cite this URL:
Prasad AK, Varanasi B, Rajendran U, Dcruze L, Subramanian S, Venkataraman J. Small bowel adenocarcinoma masquerading as ileocolic intussusception. Gastroenterol Hepatol Endosc Pract [serial online] 2022 [cited 2022 Aug 14];2:96-8. Available from: http://www.ghepjournal.com/text.asp?2022/2/3/96/349952




  Introduction Top


We present a case of recurrent abdominal pain that presented acutely with a mass in the left lumbar region that was confirmed preoperatively as ileocolic intussusception. Peroperatively, there was an ileal tumor (adenocarcinoma) that had intussuscepted to the descending colon.


  Case Report Top


An 83-year-old male presented with a history of crampy abdominal pain around the umbilicus for 10–12 days with a history of mild abdominal distension and two episodes of vomiting. Antedating this presentation, the patient gives a history of a fall in hemoglobin (Hb) from 12 g/dL to 8 g/dL in May 2021 which was detected during preoperative workup for the cataract surgery. Thereafter, there has been a history of fatigue and asthenia and progressive loss of appetite and weight. He remained uninvestigated and was supplemented with iron tablets for the correction of anemia.

The patient had no comorbidity and was not on any long-term medication. Bowel movements were normal; no history of bleeding per rectum or melena.

On examination, the patient was thin built with body mass index of 23 kg/m2. Pallor was significant. Vitals were stable. There was a small subcutaneous nodule in the forehead. Abdomen examination revealed a nontender 7 cm × 8 cm mass in the left hypochondrium astriding a part of the left lumbar region. Mass was firm in consistency, smooth surface, bimanually palpable but not ballottable; plane of the mass was intra-abdominal with no intrinsic mobility. It was not reducible and there was no gurgle. Ultrasound done elsewhere revealed dilated small bowel loops and a mass/colonic growth in the left lumbar region. Intussusception was considered in the differential.

Baseline investigations revealed iron-deficiency anemia (Hb 8.8 g/dL, low mean corpuscular volume, and mean corpuscular hemoglobin concentration), white blood cell count of 17,550 cells/cu. mm, and platelet count of 3.71 L/cu. mm. Differential count showed a polymorph leukocytosis. Liver biochemistry: serum bilirubin 1.85 mg/dL; aspartate transaminase and alanine transaminase 52 and 22 U/L, respectively, and normal serum alkaline phosphatase. An emergency multiphasic computed tomography (CT) was done [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d, [Figure 1]e. Colonoscopy was done with intent to reduce the intussusception. An ulcerated growth was seen protruding out of the intussusceptum, with a viable surrounding intestinal mucosa. However, attempt was not successful [Figure 2]. Histopathology of the colonoscopy was suggestive of moderately differentiated adenocarcinoma with mucinous features.
Figure 1: Axial section (a and b) showing small bowel intussuscepting into the intussuscipiens (colon) coronal (c) and sagittal section (d and e) showing spring coil appearance of the intussuscipiens and dilated small bowel loops

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Figure 2: Colonoscopic view of the nonreducible nodular ulcerated growth in the descending colon

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The patient was taken up for laparotomy.

At surgery, small bowel loops were grossly distended. An attempt was made to reduce the intussusception, but was not successful and since it was an ileocolocolic intussusception extending up to the descending colon, a subtotal colectomy was done [Figure 3]. The terminal portion of resected small bowel (ileum) was anastomosed to the descending colon. Immediate postoperative period was uneventful. Cut open section of the surgical specimen revealed a nodular growth in the ileum that was serving as the lead point resulting in intussusception [Figure 3]. Biopsy report confirmed the earlier findings, suggestive of G2 moderately differentiated adenocarcinoma [Figure 4], pT2 pN0.
Figure 3: Resected specimen showing a terminal ileal tumor that had intussuscepted to the splenic flexure-descending colon region

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Figure 4: Clusters of tumor cells floating in large extracellular mucin lakes

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  Discussion Top


Intussusception was reported for the first time in 1674 by Barbette of Amsterdam. Intussusception, or “introsusception” as it was named then, was later detailed in 1789 by John Hunter. Our patient had an ileal tumorous lesion, presenting as anemia for more than 6 months and subsequently masquerading as small bowel partial obstruction progressing to complete obstruction.

Approximately, 5%–10% of all cases of intussusception is seen in adults with <5% of all adult intestinal obstructions being ascribed to intussusception.[1] Small bowel adenocarcinoma is rare. Chiang and Lin[2] reported neoplastic lesions as cause for intestinal intussusception in 92% (colonic 63% and enteric 20%) and idiopathic in the remaining. Most colonic tumors in their series were adenocarcinomas (80%) and remaining lymphomas (20%). Lesions in the small bowel were of benign lipoma (38%) and Peutz–Jeghers and malignant were lymphoma and metastatic tumors. In recent times, neuroendocrine carcinoma is the most common tumor (39%–45%), often localized in distal segments of the small intestine, followed by small bowel adenocarcinoma 31%–40%. Other risk factors include endometriosis, Meckel's diverticulum, or even appendiceal pathology.

Adults often exhibit chronic nonspecific symptoms including nausea, changes in bowel habits, and gastrointestinal bleeding,[1] with an average delay of 6–8 months[3] in confirming the diagnosis. Anemia as in our patient is often missed and ignored. Majority of the adult intussusception patients (90%) report crampy periumbilical abdominal pain that is intermittent with periodicity. A quarter of the patients present with small bowel obstruction and <10% as perforation. The delay in diagnosis results in patients presenting at a late-advanced stage.[3]

Imaging methods can contribute greatly to the diagnosis of this condition. Abdominal CT scan is the most sensitive radiological modality, with sensitivity ranging from 71.4% to 87.5%, and specificity, in adults, close to 100%. The classic CT finding is the “target” sign or “sausage-shaped” soft-tissue mass. Ultrasound is useful and can show the classic “target” sign in transverse sections and the “pseudo-kidney” sign in longitudinal sections.

The treatment of intussusception in adults is surgical because of the high incidence of underlying malignant pathology and serious complications that can develop as a result of intestinal obstruction and vascular strangulation.[4],[5]

It remains debatable whether reduction of the intussuscepting lesion should be attempted preoperatively or at laparotomy or whether “en bloc” resection should be carried out without attempting reduction. Our patient was an elderly male in the 9th decade. Early surgery and decision to be taken during laparotomy was considered. Chang et al. recommend operative reduction for small bowel intussusceptions but not for colonic intussusceptions.[6] Begos et al. are proponents of resection without attempting reduction when the bowel is inflamed, ischemic, or friable and in colocolic intussusception (with the high likelihood of malignancy).[7] In our patient, not only was there a risk of malignancy contemplated, but also the chronic intussusception at laparotomy showed the entire distal small loop to be densely adherent precluding attempts of a safe reduction, and hence, subtotal colectomy was done. Only few case reports are there of such compound intussusceptions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, et al. Intussusception of the bowel in adults: A review. World J Gastroenterol 2009;15:407-11.  Back to cited text no. 1
    
2.
Chiang JM, Lin YS. Tumor spectrum of adult intussusception. J Surg Oncol 2008;98:444-7.  Back to cited text no. 2
    
3.
Yalamarthi S, Smith RC. Adult intussusception: Case reports and review of literature. Postgrad Med J 2005;81:174-7.  Back to cited text no. 3
    
4.
Wang N, Cui XY, Liu Y, Long J, Xu YH, Guo RX, et al. Adult intussusception: A retrospective review of 41 cases. World J Gastroenterol 2009;15:3303-8.  Back to cited text no. 4
    
5.
Honjo H, Mike M, Kusanagi H, Kano N. Adult intussusception: A retrospective review. World J Surg 2015;39:134-8.  Back to cited text no. 5
    
6.
Chang CC, Chen YY, Chen YF, Lin CN, Yen HH, Lou HY. Adult intussusception in Asians: Clinical presentations, diagnosis, and treatment. J Gastroenterol Hepatol 2007;22:1767-71.  Back to cited text no. 6
    
7.
Begos DG, Sandor A, Modlin IM. The diagnosis and management of adult intussusception. Am J Surg 1997;173:88-94.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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