Adult intussussception by tumor in ileum. A diagnostic dilemma. Int J Student Res 2012

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Diaz-Rosales et. al. Int J Stud Res 2012;2(1):18-20
Adult intussusception by tumor in ileum: a diagnostic
dilemma
Juan de Dios Diaz-Rosales, Lenin Enriquez-Dominguez, Jose R Castillo-Moreno, Pedro G
Gutierrez-Ramirez
Introduction
The intussusception exists when a proximal segment of
bowel (intussusceptum) telescopes into the lumen of the
adjacent distal segment (intussuscipiens) [1]. Although it is
very common in pediatric population (1-4 cases by 1000 live
births), this entity is rare in adults (1-3 cases by each
millions of habitants by year), and represents 1% of patient
with bowel obstructions and 5% of all intussusceptions [2].
In this report, we present two cases of ileo-colic
intussusceptions in adults, both with a pre-operative
diagnosis of complicated acute appendicitis and post-
operative diagnosis of intussusception by a distal ileal tumor.
Case Presentation
Case 1
An 18-year-old Mexican male, without pathologic medical
history was admitted in the emergency room (ER) of General
Hospital of Ciudad Juarez (México) with abdominal pain
syndrome. He had a fifteen-day history of abdominal
cramping pain (mild to moderate severity) in inferior right
quadrant (IRQ); nausea and vomiting, hyperthermia, and
malaise were present at the time of presentation. He was
treated by his family physician with analgesics and
antibiotics without improvement, and the symptoms
persisted and the pain became severe and intractable. On
examination, the patient was conscious, alert and oriented.
He was afebrile with a heart rate (HR) of 92 beats per
minute, respiratory rate (RR) 26 cycles per minute and blood
pressure (BP) of 100/70 mmHg. Abdominal examination
revealed a mass in the in Right Lower Quadrant (RLQ).
McBurney’s sign, Psoas sign and Obturator sign were
positive. Blood work up showed raised white blood cell
count at 11,680 per mm3
. Other hematological parameters
were unremarkable. Plain abdominal films demonstrated
signs of intestinal obstruction, air-fluid levels in small bowel
and absence of air in the large bowel. Ultrasonography
revealed a mass in the RLQ, and evidence of free fluid in
lower abdomen. The pre-operative diagnosis of acute
appendicitis and Meckel´s diverticulum was made. The
patient underwent an emergent median laparotomy. During
the operation, an ileo-ceco-colic intussusception was found;
during reduction, a small mass into the ileal lumen was
discovered. It was located in the region of distal ileum
(Figure 1A). A right hemicolectomy with resection of
affected ileal segments (approximately 20 cm) was
performed. The continuity of the digestive tube was
reestablished by primary double-layer end-to-end ileum-
transvers anastomosis with 3.0 silk and 3.0 polyglactin 910.
The anatomical pathology report revealed a submucosal
tumor of the ileum, about 3 cm x 3 cm, with features of non-
Hodgkin lymphoma (intermediate grade) (Figure 2A). The
post-operative period was uncomplicated and he was
discharged on the 7th
day following surgery. At the time of
discharge, his presenting symptoms resolved and was
referred to the oncology service for further assessment.
Figure 1 Gross image. A: Case 1- Mass resected from the
ileal lumen. B: Case 2- Transoperative enterotomy of ileum
showing a polypoid mass in the inner of the lumen
Case 2
A 25-year-old Mexican female, without pathologic medical
history was admitted in the ER of our hospital with
abdominal pain syndrome. The patient presented with a
three-day history of abdominal discomfort with intermittent
abdominal cramping pain of mild to moderate in severity,
and localized around the mesogastric area, and progressed
gradually into a severe pain with radiation to the right iliac
quadrant. She also had nausea accompanied by 3 episodes of
vomiting. She was afebrile with stable vital signs.
Examination revealed a distended abdomen with rigidity and
guarding with raised local temperature. An abdominal mass
was palpated in the RLQ; Rovsing and Giordano signs were
Department of Surgery, Hospital General De Ciudad Juarez,
Universidad Autonoma De Ciudad Juarez, Mexico
Corresponding Author
Juan de Dios Diaz-Rosales,
Email: juandedios_uacj@yahoo.com.mx
ABSTRACT
Intussusception in adults is an infrequent cause of intestinal obstruction; preoperative diagnosis is difficult
as symptoms can be intermittent and long standing. This relatively rare entity differs from the childhood
form in its etiology, presentation and treatment. We present two cases of ileo-colic intussusception in adults,
with a clinical presentation that mimicked complicated appendicitis. These cases remind us that both ileal
tumors and intussusception must be included in the diagnosis of lower abdominal pain.
Key Words: Intussusception, carcinoid tumor, non-Hodgkin lymphoma, ileocecal valve.

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Diaz-Rosales et. al. Int J Stud Res 2012;2(1):18-20
elicited. Bowel sounds were absent. Laboratory results were
unremarkable except for mild elevated white blood counts at
12,600 per. Plain abdominal films showed air-fluid levels,
with the sentinel loop sign in RLQ. A diagnosis of small
bowel obstruction by complicated appendicitis was made.
The patient underwent an emergency median laparotomy.
During surgery, an ileo-cecal intussusception was found and
reduced. A small mass of size 2 cm x 3 cm in the lumen of
ileum was discovered (Figure 1B). The appendix appeared
without evidence of pathology. A resection en-block of the
affected segment was performed. The histopathological
examination revealed a submucosal endocrine-like tumor of
the ileum with homogenous aspect formed by monotonous
sheet of cells containing small compact nuclei that were
uniform and contained dense granules, forming nests with
invasion to serous layer, suggestive of a well differentiated
invasive carcinoid tumor (Figure 2B). The patient underwent
a second operation on the 3th
post-operative day, and a right
hemicolectomy was performed, there was no evidence of
nodes or metastases (IIIA). Post-operative period was
uneventful and she was discharged on the 5th
post-operative
day. Following discharge she was referred to the oncological
service for further evaluation.
Figure 2 Histopathological examination (100X
magnification). A: Lymphoid tissue with loss of
architecture, proliferations of atypical lymphoid cells. B:
Cells with eosinophilic cytoplasm and hyperchromic
nucleus that depicts a carcinoid tumor.
Discussion
While intussusceptions in children have an idiopathic
etiology in 95% cases, the condition is almost always
secondary to a definable lesion (intra-luminal lesions in
90%) in adults patients [2-4]. The mechanism of
development is believed that any lesion in the intestinal wall
alters normal peristalsis, and is able to initiate an
invagination [5].
The intussusception is broadly classified as: jejuno-jejunal,
ileo-ileal, ileo-colic, ileo-cecal-colic, colo-colonic, sigmoido-
rectal, and appendicico-cecal [5,6]. The adult intussusception
presents with a variety of non-specific symptoms that can
have an acute, intermittent, and or chronic abdominal pain
[7] and bowel obstruction which can either be complete or
intermittent [8]. Only about 9 to 10% of adult patients
present with the typical triad of abdominal pain, palpable
abdominal mass and bloody stool, and hence, the
preoperative diagnosis is difficult [9].
In our cases, the core symptom was abdominal pain;
insidious in the teenager and acute in adult patient. With
such a presenting symptomatology and a palpable mass in
the RLQ, a diagnosis of appendicitis was made. Although
the large evolution of the boy was atypical for appendicitis,
for this, the differential diagnosis was Meckel´s
diverticulum. However intra-operatively, this appendicitis-
mimicking presentation turned out to be an ileo-ceco-colic
intussusceptions.
Abdominal ultrasound and Computed Tomography (CT)
scan are the most effective diagnostic methods [2], although
a number of different methods are available: barium
imaging, endoscopic examination, and angiographic and
radionucleotide studies [9]. Abdominal ultrasound and CT
scan have high sensibility and specificity; and both shows a
classic image of “target” or “sausage” shape mass.
Endoscopic examination is therapeutic in children, but in
adults it does not have any considerable hydrostatic
reduction effect, because of high incidence of underlying
anatomical abnormalities [10], like these cases (inner ileal
tumors). Our clinical scenario comprised of patients with
abdominal pain syndrome in an ER of a secondary health
care hospital in Mexico. All the patients presenting with such
a symptomatology are clinically evaluated and subjected to
an abdominal x-ray and subsequently abdominal
ultrasonography. Similar situation exists in many developing
countries where facilities of high resolution imaging might
not be available specially in secondary health care catering
centers and the diagnosis is mostly relied upon clinical
impression and basic imaging modalities like the
roentgenogram and sonography. In such a setting, like in our
cases, a high suspicion of a possible intussusception should
be considered as this may pose a diagnostic dilemma to the
clinician where facilities of Magnetic Resonance Imaging
(MRI) and CT scanning are not available.
In adults, surgery is necessary and imperative, because of the
high incidence of underlying anatomical abnormalities [5,6].
Most studies agree that resection is necessary; this could be
en-block [6], because this entity is secondary to a neoplasm
into the lumen of bowel, and majority are malignant. It
remains debatable whether reduction should be attempted or
whether en-block resection should be carried out without
attempting reduction [9,10]. In the first patient, we
performed a hemicolectomy, because we suspected that the
tumor was malignant. In the second patient, we did know

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Diaz-Rosales et. al. Int J Stud Res 2012;2(1):18-20
exact the origin of the tumor, and thus the resection of only
the distal ileum and cecum was performed, as we did not
have a definitive diagnosis of carcinoid tumor until the
pathological evaluation. Following the histopathological
analysis, the patient underwent a hemicolectomy without
complications.
Conclusion
A differential diagnosis of small bowel intussusception
should be kept in consideration in cases presenting with
lower abdominal pain. The clinical presentations of such
cases may at times mislead to a definitive diagnosis and
often cause a diagnostic dilemma, especially in centers
where high resolution imaging modalities are not available.
A high suspicion index by the clinician is imperative to not
rule out an ileal pathology causing intussusceptions in such
cases. The management of such cases consists of surgical
resection en-block, however the resection of only the
affected segment can be validated when the diagnosis of
pathology is reported, and resection en-block could be
performed later.
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Consent
Written informed consent was obtained from the patient for
publication of this case report and any accompanying
images. A copy of the written consent is available for review
by the editor-in-chief of this journal.
Authors’ Contributions
PGG, LE and JDR participated in clinical diagnosis and
surgery of both the patients. JRC, LE and JDR contributed
with literature search and drafting of the manuscript. JRC
and LE contributed with review of the manuscript.
Competing Interests
The authors declare that they have no competing interests.
Funding
Sources of funding- None
Please cite this paper as: Diaz-Rosales J, Enriquez-
Dominguez L, Castillo-Moreno JR, Gutierrez-Ramirez PG.
Adult intussusception by tumor in ileum: a diagnostic
dilemma. Int J Stud Res 2012;2(1):18-20.
doi: http://dx.doi.org/10.5549/IJSR.2.1.18-20
Received: 23 Nov 2011, Accepted: 15 Mar 2012
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