A 24-year-old male with a history of microscopic hematuria presented to the emergency department (ED) with left lower quadrant abdominal pain. His pain started about two weeks ago and has been intermittent. He describes the pain as stabbing. He decided to come to the ED today because of the persistent nature of the pain. He denies chest pain, cough, shortness of breath, fevers, nausea, vomiting, diarrhea, constipation, rectal bleeding, dysuria, and increased urinary frequency. His exam revealed a well-appearing male in no acute distress. His abdomen was soft with left lower quadrant tenderness on palpation but no rebound or guarding. A CT Abdomen/Pelvis with IV contrast was obtained with the following images:

Axial View

Coronal View

What is the diagnosis?

Intussusception

Explanation:

Intussusception is a telescoping of a proximal segment of the GI tract into the lumen of the adjacent distal segment of the GI tract.

The axial image of the left side of the abdomen shows a dilated small bowel loop with a target-like appearance, typical of intussusception.  Coronal imaging shows that the intussusception is approximately 4.5 cm long.

Intestinal intussusception is classically a diagnosis associated with childhood. Adult cases of intussusception are quite rare and only account for about 5% of all cases [1]. Only 1-5% of all cases of bowel obstructions are secondary to adult intussusception [1-2].

Etiologies of adult intussusception include [2]:

• Inflammatory bowel disease
• Adhesions due to past surgeries
• Meckel’s diverticulum
• Benign tumors
• Malignant tumors
• Iatrogenic (e.g., intestinal tubes, feeding tubes, gastric surgery)
• Idiopathic (8-20% of cases)

CT Abdomen/Pelvis is the diagnostic modality of choice [3].

Treatment typically involves surgery with surgical resection. The possibility of a malignant lesion also needs to be assessed.

Case Conclusion:

Surgery was consulted.  The patient’s pain was resolved when they saw the patient in the emergency department.  Therefore, the surgeon did not believe that the patient needed urgent surgery.  However, surgery did recommend a fluoroscopic small bowel series for further evaluation, which ultimately came back unremarkable.  Subsequently, the surgeon’s recommendation was to discharge the patient home with a plan for an outpatient colonoscopy to assess for malignancy.  The colonoscopy was completed only a few days later which only revealed benign polyps.

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References

1. Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, Theodosopoulos T. Intussusception of the bowel in adults: a review. World J Gastroenterol. 2009;15(4):407.  PMID 19152443.
2. Zubaidi A, Al-Saif F, Silverman R. Adult Intussusception: A Retrospective Review. Dis Colon Rectum. 2006 Oct;49(10):1546-51. PMID 16990978.
3. Azar T, Berger DL. Adult intussusception. Ann Surg. 1997;226:134–138.  PMID 9296505.