Intussusception in adults is an uncommon entity with various clinical manifestations and complications such as acute gastrointestinal bleeding. We reported a 30-year-old man who referred to our hospital with loss of consciousness and developed two separate courses of acute gastrointestinal bleeding after admission. During second surgery, we came across a jejunojejunal intussusception as the main cause of gastrointestinal bleeding. Hereby, we reviewed and analyzed our experience in the management of this disease and also compared our findings with respective literature and other studies.&nbsp

Ebrahimian, Manoochehr

Kialashaki, Mehrnoosh

English

Journals Portal, Shahid Beheshti University of Medical Sciences

School of Medicine Students‘ Journal (2020) 2:4 • 9Acute Gastrointestinal Bleeding Caused by Jejunojejunal Intussusception in an Adult: A Case Report and Literature ReviewManoochehr Ebrahimiman1, Mehrnoosh Kialashaki11- Resident of General Surgery, General surgery department, Loghman Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.Intussusception in adults is an uncommon entity with various clinical manifestations and complications such as acute gastrointestinal bleeding. A 30-year-old man was re-ported who referred to our hospital with loss of consciousness, and developed two separate courses of acute gastrointestinal bleeding after admission. During second surgery, we came across a jejunojejunal intussusception as the main cause of gas-trointestinal bleeding. Hereby, we reviewed and analyzed our experience in the man-agement of this disease and also compared our findings with respective literature and other studies. ABSTRACTCite This Paper as Ebrahimiman M, Kialashaki M. Acute gastrointestinal bleeding caused by Jejunojejunal intussusception in an adult: a case report and litera-ture review. Sch Med Stud J.2020;2(4):9-12Corresponding AuthorManoochehr EbrahimianAddress: Loghman Medical Center, Kamali Ave, Tehran, Iran.Postal code: 1333635445Tel: +98 911 342 3866INTRODUCTIONAlthough intestinal intussusception is a common disorder in children, but it is a rare condition in adults and may present with various clinical manifestations such as abdominal pain, constipation, nausea and vomiting and diarrhea [1]. Acute gastrointestinal bleeding due to intussusception is one of the uncommon presentations of the disease and can be fatal if not treated properly. Here we report a case with unexplained intestinal invagination and review our experience in diagnosis and management of the disease.CASE PRESENTATIONA 30-year-old man referred to our hospital’s emergency de-partment with loss of consciousness. He was admitted with a diagnosis of multidrug toxicity in intensive care unit and re-ceived respective treatment. Due to the patient’s altered mental status we could not take a thorough history of his addiction and drug regimen. On the other hand, laboratory toxicity pan-els only showed increased levels of amphetamines and opi-oids. During the first 24 hours, the nasogastric tube contents became coffee ground, repeated episodes of melena found and hemoglobin level decreased to 6 g/dL. Upper gastrointestinal endoscopy showed a 15 mm clean based ulcer in doudenal bulb and no ongoing active bleeding was seen. He did not respond to resuscitative treatment despite six units of PRBCs transfu-sion. The patient was taken to the operating room and mid-line celiotomy was performed. After gastrotomy, we found a 15 mm ulcer with non-bleeding visible vessel and another one cm clean based ulcer in posterior wall of duodenal bulb (Fig-ure 1). Both ulcers were ligated and sutured with a thick silk thread and pyloroplasty in the style of Heineke-Mikulicz was performed. Other intra-abdominal organs were normal without any pathological findings. The patient developed a low-grade fever (38.1°C) on the third day of post-operative period and in abdominopelvic CT, no pathologic findings were detected. The patient discharged four days after surgery. Nine days later he Article InfoDate Submitted: 31 October, 2020Date of acceptance: 14 December, 2020KeywordsAcute gastrointestinal bleeding, Intussus-ception, Adult intussusception, Jejuno-jejunal, Intestinal invagination, Melena, Hematemesis, Coffe ground vomitingdoi:10.22037/smsj.v2i4.32639Case Report  SMSJournal.netBAFigure 1. photographs taken from first surgery. A: a 15mm clean based ulcer located at the posterior wall of duodenal bulb. B: a non-bleeding visible vessel located near the same ulcer10 • School of Medicine Students‘ Journal (2020) 2:4dence and prevalence. Some reported intussusception in adults represents in less than 1% of patients with bowel obstructions [2]. Anatomically intussusception also called invagination which could be found in entire gastrointestinal tract such as gastroesophageal junction, duodenum, small bowel, large bow-el and even rectum [3-6]. Intussusception also is reported re-peatedly in other animals like cats, dogs, horses and mice. On the other hand, it seems that the disease is not limited to mam-mals and can be found in other vertebrates too [7]. Intussusception usually presents in infants between 6 and 36 months of age but it can appear in older ages too [8]. Generally, the involved bowel causes obstruction and the patient presents severe progressive abdominal pain that is crampy and occurs every 15 to 20 minutes [8]. Several intussusception sites have been described but the most common type is ileocecal or ileo-colic that accounts for more than 90% of all patients [9].Generally, this condition in adults is quite different from chil-dren in etiology. In children, it is usually benign without any secondary lesions but in adults it is secondary to various patho-logic triggers called “Lead points”. In a large retrospective study in 1970, a total of 160 cases were reviewed and results indicate that less than 10% of intussusceptions were primary or without unexplained etiology [10].developed another course of loss of consciousness, bleeding, melena and decreased Hb level (Hb=4 g/dL). Due to patient’s hemodynamic instability, he was taken to the operation room one more time. Two liters of reactive liquid was found in the abdominal cavity which had aspirated completely. Prior sur-gery site was in an appropriate condition. Several patchy isch-emic points and one perforation, were found in 100 centimeters away from Treitz ligament (Figure 2). At 200 cm away from Treitz, small bowel intussusception was seen (Figure 3). Distal to intussusception site, dark bloody contents were observable through small bowel wall. So, the involved bowel were resect-ed and an end-to-end anastomosis was performed (Figure 4). The patients tolerated oral regimen 4 days after surgery and was discharged afterwards. Surgical specimen pathology ex-amination indicated 15 reactive lymph nodes and confirmed small bowel intussusception. Further radiologic studies like thoracoabdominal CT showed no suspicious lesions for malig-nancy. RDISCUSSIONIntussusception is defined as a condition in which a proximal segment of bowel (intussuscepted) moves through adjacent distal segment (intussusceptions). This condition is common among children but can be found rarely in adults. Considering its scarcity, there is not much data reporting its precise inci-Acute Gastrointestinal Bleeding Caused by Jejunojejunal IntussusceptionFigure 2. images from second surgery. A: dilated small bowel loop and some patterns of patchy necrosis alongside the bowel wall. B: perforation site. Extracted bowel contents show melena.A BFigure 3. jejunojejunal intussusception found during abdominal explorationFigure 4. resected bowel. A: intussusception site. B:100 cm specimen including perforation site and necrotized bowelA BSchool of Medicine Students‘ Journal (2020) 2:4 • 11Despite ileocolic type which is the most common in children, several studies reported a wide range of involved sites. For example, almost half of the patients in the study mentioned above had colonic etiologies. On the other hand, some authors reported that enteric type is more common.[11]. But it is obvi-ous that intussusception can occur in any location inside gas-trointestinal tract, that are junctions between freely and fixed moving segments. So it can potentially involve duodenum that is adhered to the retroperitoneal structures and jejunum as well as ileum, ascending and descending colons and rectum with the same rationale. However it seems that colonic etiologies are more likely to be malignant [12].In adult, this condition is not typically like infants and can be presented with a wide variety of clinical manifestations like abdominal pain, nausea and vomiting, constipation, diarrhea, gastrointestinal bleeding, mass palpation and weight loss [1]. Acute gastrointestinal bleeding (GIB) can occur in these pa-tients as mentioned above but none of case series described precisely this compliant and related etiologies. One report de-scribed a 65-year-old female patient with hemangioma in ile-um that developed intussusception and the involved section of bowel was resected [13]. Also cases of acute GIB with etiolo-gies of metastatic testicular germ cell cancer, metastatic lung cancer, hepatocellular carcinoma, vascular hamartoma and li-poma have been described in literature [14-18].Table 1 shows summarized reports data. No colonic intussusception in the context of acute GIB has been reported. It seems that jejuno-jejunal types are more prone to cause bleeding. All cases men-tioned underwent surgery and the involved intestinal site of GIB had been resected. Regarding pathology reports, it seems that it is imperative to resect the affected segment of bowel because of high rate of malignant lesions. In our case we also resected the affected site and pathology reported no significant lesion. Thoracoabdominal Computed Tomography (CT) also showed nothing special and the patient was discharged.CONCLUSIONAcute gastrointestinal bleeding is a rare manifestation of in-tussusception in adults and usually is found incidentally inside surgeries. Because of high risk of malignancy in these patients, the surgeon should keep in mind that every lesions causing acute gastrointestinal bleeding in the context of intussuscep-tion must be resected and further radiologic evaluation should be performed. CONFLICT of INTERESTNone of the authors have any conflict of interest. No funding was received for this study. The study is not an official represen-tative or on behalf of the government.REFRENCES1. Erkan N, Hacıyanlı M, Yıldırım M, Sayhan H, Vardar E, Polat AF. Intussusception in adults: an unusual and challenging con-dition for surgeons. International Journal of Colorectal Disease. 2005;20(5):452-6.2. Azar T, Berger DL. Adult intussusception. Ann Surg. 1997;226(2):134-8.3. Lukish JR, Eichelberger MR, Henry L, Mohan P, Markle B. Gastroesophageal intussusception: a new cause of acute esoph-ageal obstruction in children. Journal of pediatric surgery. 2004;39(7):1125-7.4. Jennings B, Doerr R. Duodenal lipoma causing intussuscep-tion. Surgery. 1989;105(4):560-3.5. Box JC, Tucker J, Watne AL, Lucas G. Eosinophilic colitis presenting as a left-sided colocolonic intussusception with sec-ondary large bowel obstruction: an uncommon entity with a rare presentation. The American surgeon. 1997;63(8):741-3.6. Dvorkin LS, Knowles CH, Scott SM, Williams NS, Lunniss PJ. Rectal intussusception: characterization of symptomatology. Diseases of the colon & rectum. 2005;48(4):824-31.7. Sabater M, Huynh M, Forbes N. Ileo-ceco-rectal intussuscep-tion requiring intestinal resection and anastomosis in a Tawny Eagle (Aquila rapax). Journal of Avian Medicine and Surgery. 2015:63-8.8. Buettcher M, Baer G, Bonhoeffer J, Schaad UB, Heininger U. Three-year surveillance of intussusception in children in Swit-zerland. Pediatrics. 2007;120(3):473-80.9. Mandeville K, Chien M, Willyerd FA, Mandell G, Hostetler MA, Bulloch B. Intussusception: clinical presentations and im-aging characteristics. Pediatric emergency care. 2012;28(9):842-4.10. Weilbaecher D, Bolin JA, Hearn D, Ogden W. Intussuscep-tion in adults: review of 160 cases. The American Journal of Surgery. 1971;121(5):531-5.11. Zubaidi A, Al-Saif F, Silverman R. Adult Intussusception: A Retrospective Review. Diseases of the Colon & Rectum. 2006;49(10):1546-51.Manoochehr Ebrahimiman et al.Table 1. Summarized cases of adult intussusceptions with acute gastrointestinal bleeding presentationReporter Case age Gender Type Surgery PathologyKim et al. 2008 65 Female ileocolic resection hemangiomaHofflander et al. 1999 27 Male jejunojejunal resection Mixed germ cell tumorYun et al. 2008 52 Male jejunojejunal resection Lung cancerYang et al. 1987 31 Male jejunojejunal Resection hepatocellular carcinomaLi et al. 2018 19 Male Ileoileal Resection Vascular hamartomaLi et al. 2018 54 Male Ileocecal Resection lipomaManouras et al. 2007 55 Male jejunojejunal resection lipoma12 • School of Medicine Students‘ Journal (2020) 2:412. Marinis A, Yiallourou A, Samanides L, Dafnios N, Anas-tasopoulos G, Vassiliou I, et al. Intussusception of the bowel in adults: a review. World J Gastroenterol. 2009;15(4):407-11.13. Kim SY, Jeon TJ, Hong JH, Kim GS, Oh TH, Seo DD, et al. [An adult case of small bowel intussusception caused by hemangioma presenting with intestinal bleeding]. The Kore-an journal of gastroenterology = Taehan Sohwagi Hakhoe chi. 2008;52(3):183-7.14. Hofflander R, Beckes D, Kapre S, Matolo N, Liu S. A Case of Jejunal Intussusception with Gastrointestinal Bleeding Caused by Metastatic Testicular Germ Cell Cancer. Digestive Surgery. 1999;16(5):439-40.15. Yun IS, Lee JY, Lee JS, Lee JY, Byun JM, Kim EJ, et al. [Jejunal intussusception with gastrointestinal bleeding caused by metastatic lung cancer]. The Korean journal of gastroenter-ology = Taehan Sohwagi Hakhoe chi. 2008;51(6):377-80.16. Yang PM, Sheu JC, Yang TH, Chen DS, Yu JY, Lee CS, et al. Metastasis of hepatocellular carcinoma to the proximal jejunum manifested by occult gastrointestinal bleeding. The American journal of gastroenterology. 1987;82(2):165-7.17. Li Z, Sun M, Song B, Shu Z. Gastrointestinal hemor-rhage caused by adult intussusception secondary to small intestinal tumors: Two case reports. Medicine (Baltimore). 2018;97(34):e12053-e.18. Manouras A, Lagoudianakis EE, Dardamanis D, Tsek-ouras DK, Markogiannakis H, Genetzakis M, et al. Lipoma induced jejunojejunal intussusception. World J Gastroenterol. 2007;13(26):3641-4.Acute Gastrointestinal Bleeding Caused by Jejunojejunal Intussusception

Acute gastrointestinal bleeding caused by Jejunojejunal intussusception in an adult: a case report and literature review

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Acute gastrointestinal bleeding caused by Jejunojejunal intussusception in an adult: a case report and literature review

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