Intussusception is the cause of around 1% of all bowel obstructions in adults. Unlike in children, where intussusception is most often idiopathic in nature, cases in adults usually have an identifiable etiology, most commonly malignancy. Symptoms are usually non-specific, but timely identification and management is crucial due to high rates of carcinoma as the lead point of intussusception. Here we present a rare case of mucinous adenocarcinoma of the colon that presented as ileoileal intussusception. Diagnostic and treatment issues are also discussed

Cervellione, Kelly L.

Chand, Prakash

Patel, Avani A.

Sulh, Muhammed

English

PubMed

Intussusception is the cause of around 1% of all bowel obstructions in adults. Unlike in children, where intussusception is most often idiopathic in nature, cases in adults usually have an identifiable etiology, most commonly malignancy. Symptoms are usually non-specific, but timely identification and management is crucial due to high rates of carcinoma as the lead point of intussusception. Here we present a rare case of mucinous adenocarcinoma of the colon that presented as ileoileal intussusception. Diagnostic and treatment issues are also discussed.</jats:p

Prakash Chand

Avani A. Patel

Kelly L. Cervellione

Muhammed Sulh

Crossref

Hindawi Publishing CorporationCase Reports in MedicineVolume 2012, Article ID 340947, 4 pagesdoi:10.1155/2012/340947Case ReportA Rare Case of Mucinous Adenocarcinoma of the ColonPresenting as Ileoileal Intussusception in an AdultPrakash Chand,1 Avani A. Patel,1 Kelly L. Cervellione,2 and Muhammed Sulh31 Department of Medicine, Jamaica Hospital Medical Center, 8900 Van Wyck Expressway, Jamaica, NY 11418, USA2 Department of Clinical Research, Jamaica Hospital Medical Center, 8900 Van Wyck Expressway, Jamaica, NY 11418, USA3 Department of Pathology, Jamaica Hospital Medical Center, 8900 Van Wyck Expressway, Jamaica, NY 11418, USACorrespondence should be addressed to Kelly L. Cervellione, kcervell@jhmc.orgReceived 20 September 2011; Accepted 12 November 2011Academic Editor: Liang Kung ChenCopyright © 2012 Prakash Chand et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Intussusception is the cause of around 1% of all bowel obstructions in adults. Unlike in children, where intussusception is mostoften idiopathic in nature, cases in adults usually have an identifiable etiology, most commonly malignancy. Symptoms areusually non-specific, but timely identification and management is crucial due to high rates of carcinoma as the lead point ofintussusception. Here we present a rare case of mucinous adenocarcinoma of the colon that presented as ileoileal intussusception.Diagnostic and treatment issues are also discussed.1. IntroductionIntussusception occurs when proximal bowel segment (in-tussusceptum) invaginates into distal bowel segment (intus-suscipiens). This may cause a loss of blood supply to the areaand intestinal obstruction. More rarely, the intussusceptummay become strangulated, necrotic, and gangrenous andlead to sepsis or death. Intussusception is a rare occurrencein adults, representing less than 5% of all cases of intus-susception [1]. Intussusception is the cause of around 1%of all cases of bowel obstructions in adults [2]. Whereasintussusception in children is often idiopathic in nature, inadults there is more often a lead point and is caused by anunderlying condition [3]. Reports have identified malignanttumors as the cause of intussusceptions in 65% to 87% ofall adult cases [3–5]. Clinically, intussusception in adultsoften presents with nonspecific symptoms such as abdominalpain, nausea, diarrhea, and rectal bleeding. The classical triadof symptoms seen in children of sausage-shaped palpablemass, red currant jelly stools, and acute abdominal pain isless often seen in adults [2, 6]. Due to the high frequencyof occurrence of intussusception secondary to malignancyin adults, surgical resection is usually indicated. Here wepresent a rare case of colon carcinoma in a young adultpresenting as intestinal obstruction secondary to ileoileal in-tussusception.2. Case ReportA 29-year-old Hispanic male presented to the medicineclinic with episodes of pain in the abdomen for 10 months.Initially the pain was in the upper abdomen and infrequent,but later progressed to the lower abdomen and becamemore severe, intolerable, frequent, and prolonged, lastingabout 15–20 minutes per occurrence. Associated symptomswere alteration in bowel movements, loss of appetite, andunintentional weight loss of about 5 pounds in 5 months. Hereported 2 episodes of rectal bleeding before coming to theclinic. He denied any vomiting or fever. Physical examinationrevealed deep epigastric and right upper quadrant tendernesswith no rebound tenderness, guarding, or abdominal disten-sion. There was no palpable mass. On rectal exam, vault wasempty and guaiac test was negative. CT scan of abdomenshowed intussusception of small bowel and thickening ofright colon (Figure 1). A few lymph nodes were seen in fatadjacent to the right colon and mesentery. He was sent tothe emergency department and was admitted to surgery forfurther evaluation and management.2 Case Reports in Medicine[R] [L](a)[R] [L]MRN:(b)Figure 1: CT scan revealed intussusception of the small bowel (a) and thickening of the right colon (b).(a)mass(b)Figure 2: Colonoscopy revealed a circumferential fungating mass in the ascending colon measuring 4 cm in length.Subsequently, colonoscopy revealed a circumferentialfungating mass in the ascending colon measuring 4 cm inlength (see Figure 2). Biopsies of the specimen showed mod-erate to poorly diﬀerentiated mucinous adenocarcinoma.Patient underwent exploratory laparotomy. Intraoperativefindings were diﬀuse peritoneal and mesenteric metastaticstudding, large extraluminal right colon cancer, and ileoilealintussusception in midileum with lead point metastatic de-posit (see Figure 3). Thirty centimeters of ileum was re-sected with ileoileal side-to-side anastomosis, and righthemicolectomy with side-to-side ileocolic anastomosis wasperformed. The patient was discharged after 6 days. Thesurgical pathology was reported as moderate to poorlydiﬀerentiated signet ring cell mucinous adenocarcinoma inproximal ascending colon with serosal and lymphovascularinvasion (see Figure 3). There was also metastatic mucinousadenocarcinoma as a lead point of ileoileal intussusceptionand omental metastasis. Stage IV A (pT4b pN2 PM1)cancer was diagnosed based on all findings. The patient wasfollowed in clinic after five weeks and was asymptomatic withgood healing of wound.3. DiscussionAdult intussusception is a rare condition representing thecause of approximately 0.003% (3 of every 100,000) ofhospital admissions in this population [7]. The diagnosisof adult intussusception is diﬃcult due to the varied,nonspecific symptoms upon presentation [2, 6]. Whereasacute abdominal pain is common in children, adults withintussusception usually report a history of intermittentabdominal pain over a long period of time. Vomiting, nausea,Case Reports in Medicine 3(a) (b)(c)Figure 3: Histopathology of colon biopsy at high power field reveals malignant cells (a). Histopathology of ileum biopsy reveals metastaticmalignancy (b). Gross histology revealed a metastatic ileal deposit as a lead point of intussusception (c).and hematochezia are also common symptoms in adults[4, 8]. Bleeding is more frequent in colonic than in ilealintussusceptions. Unlike in pediatric populations, where apalpable, sausage-shaped mass can often be felt on physicalexamination, abdominal masses are palpable in as few as10% of cases in adults [2, 6]. As in our patient, enteric in-tussusception often presents as abdominal pain, nausea, andvomiting. Colonic intussusception may present with consti-pation, lower GI bleed, and loss of weight.Whereas intussusception in pediatric patients is usuallyidiopathic in nature, fewer than 10% of cases in adults aredue to an unknown cause [9]. In adults, studies have shownthat intussusception is caused by malignant tumors in upto 87% of cases, depending on the site of the lead point,with most others being caused by benign tumors [3–5].The highest rates of malignancy are in the colon, whereasmalignancy in enteric intussusception is less frequent [10].Correct preoperative diagnosis is made in less than 50%of cases of adult intussusception [2]. Likelihood of correctdiagnosis increases with the use of radiological tests, espe-cially CT scans [2, 4, 11]. The classical findings on abdominalCT scans are target signs or doughnut signs on cross-sectionand pseudokidney signs on coronal sections [12]. In ourcase, like previous reports [11], we were able to diagnoseileoileal intussusception preoperatively using CT. Bariumstudies and ultrasonography may also aid in diagnosis.Colonoscopy is useful when presenting symptoms indicatecolonic obstruction or CT scan points to colonic pathology[13].There is some controversy surrounding the most appro-priate methods for management of adult intussusception.Depending on the location, etiology, suspicion of malig-nancy, and clinical condition of the patient, several methodscould be utilized. However, in adults, surgical resectionof the lesion is most often indicated, especially in colonicintussusception given the high likelihood of malignancy. Insome cases, reduction of the lesion prior to resection may beperformed. In enteric intussusception, operative reductionmay be attempted if the bowel is not ischemic or friableand malignant lesion is not suspected [4, 9, 14]. In general,prognosis in adult patients with intussusception due tononmalignant causes is good. Unfortunately, since a vastnumber of patients develop intussusceptions secondary tomalignant lesions, the overall survival rate in this population4 Case Reports in Medicineis adversely aﬀected. Mortality due to intussusception inadult cases where the lead point is a benign lesion is lessthan 10%, whereas mortality in cases where malignancy isthe causative factor is over 50% [2]. In our patient, evenafter extensive surgical resection with right hemicolectomyand resection of ileal intussusception, prognosis is still poorbecause of advanced disease, poor diﬀerentiation, and signetring cell histology.In conclusion, adult intussusception is a rare and chal-lenging entity for clinicians due to the nonspecific symptomsthat accompany the diagnosis. CT scan of the abdomen is themost useful and less invasive tool for diagnosis. Operativeresection without reduction is the preferred treatment inadults as there is high risk of underlying malignancy.References[1] F. P. Agha, “Intussusception in adults,” American Journal ofRoentgenology, vol. 146, no. 3, pp. 527–532, 1986.[2] T. Azar and D. L. Berger, “Adult intussusception,” Annals ofSurgery, vol. 226, no. 2, pp. 134–138, 1997.[3] D. M. Nagorney, M. G. Sarr, and D. C. McIlrath, “Surgicalmanagement of intussusception in the adult,” Annals of Sur-gery, vol. 193, no. 2, pp. 230–236, 1981.[4] D. G. Begos, A. Sandor, and I. M. Modlin, “The diagnosis andmanagement of adult intussusception,” American Journal ofSurgery, vol. 173, no. 2, pp. 88–94, 1997.[5] A. Rosie`re, L. de Cannie`re, R. Frangi, and L. A. Michel, “Earlydiagnosis of adult intestinal intussusception at four diﬀerentlocations,” Acta Chirurgica Belgica, vol. 94, no. 6, pp. 314–317,1994.[6] L. K. Eisen, J. D. Cunningham, and A. H. Aufses, “Intussus-ception in adults: institutional review,” Journal of the AmericanCollege of Surgeons, vol. 188, no. 4, pp. 390–395, 1999.[7] M. J. Coleman, T. B. Hugh, R. E. May, and M. J. Jensen,“Intussusception in the adult,” Australian and New ZealandJournal of Surgery, vol. 51, no. 2, pp. 179–180, 1981.[8] C. C. Chang, Y. Y. Chen, Y. F. Chen, C. N. Lin, H. H. Yen, andH. Y. Lou, “Adult intussusception in Asians: clinical presen-tations, diagnosis, and treatment,” Journal of Gastroenterologyand Hepatology, vol. 22, no. 11, pp. 1767–1771, 2007.[9] M. Barussaud, N. Regenet, X. Briennon et al., “Clinical spec-trum and surgical approach of adult intussusceptions: a mul-ticentric study,” International Journal of Colorectal Disease, vol.21, no. 8, pp. 834–839, 2006.[10] D. Weilbaecher, J. A. Bolin, D. Hearn, and W. Ogden, “In-tussusception in adults. Review of 160 cases,” The AmericanJournal of Surgery, vol. 121, no. 5, pp. 531–535, 1971.[11] M. Dujardin, B. Op de Beeck, and M. Osteaux, “InvertedMeckel’s diverticulum as a leading point for ileoileal intussus-ception in an adult: case report,” Abdominal Imaging, vol. 27,no. 5, pp. 563–565, 2002.[12] J. G. Lorigan and R. A. DuBrow, “The computed tomographicappearances and clinical significance of intussusception inadults with malignant neoplasms,” British Journal of Radiol-ogy, vol. 63, no. 748, pp. 257–262, 1990.[13] LM Hurwitz and S. L. Gertler, “Colonoscopic diagnosis ofileocecal intussusception,” Gastrointestinal Endoscopy, vol. 32,pp. 217–218, 1986.[14] K. Takeuchi, Y. Tsuzuki, T. Ando et al., “The diagnosis andtreatment of adult intussusception,” Journal of Clinical Gas-troenterology, vol. 36, no. 1, pp. 18–21, 2003.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

Case Reports in Medicine

A Rare Case of Mucinous Adenocarcinoma of the Colon Presenting as Ileoileal Intussusception in an Adult

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A Rare Case of Mucinous Adenocarcinoma of the Colon Presenting as Ileoileal Intussusception in an Adult

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