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The Case Files: An Unusual Diagnosis that Started with Abdominal Pain

Zhang, Billy; Hughes, Kristen; Khan, Shamim MD; Jacome, Francisco MD

doi: 10.1097/01.EEM.0000520073.25233.90
The Case Files

Mr. Zhangis a third-year medical student at the University of Medicine and Health Sciences (UMHS) in St. Kitts. Ms. Hughesis a fourth-year medical student UNHS. Dr. Khanis a graduate of UMHS. Dr. Jacomeis a bariatric and general surgeon at the department of surgery at Doctors Hospital of Augusta in GA.

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A 51-year-old woman presented to the emergency department with severe mid-abdominal pain that had begun early that morning and progressively worsened. The patient also reported having loose bloody stools, bouts of nausea, and several episodes of vomiting yellow bilious fluid.

Her medical history was negative for similar episodes. Past medical history was significant for asthma, gastroesophageal reflux disease, hyperlipidemia, hypertension, colonic polyps, constipation, and thyroid disease. Surgical history included cholecystectomy, C-section, and Nissen fundoplication. Social history was significant for smoking. Her vital signs were within normal limits, but complete blood counts showed white blood cells were elevated to 16.58 thous/uL with left shift of neutrophils, 11.6%. Abdominal CT scan demonstrated the classic target-like sign (photo), indicating an intussusception of the ileocolic area with secondary partial bowel obstruction. (BMJ Case Rep 2014 Jun 20; 2014, doi: 10.1136/bcr-2013-203156; Radiol Med 2015;120[1]:105.)

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Sudden Pain Onset

Clinically, intussusception presents with sudden onset of episodic cramping and abdominal pain. It may be associated with emesis, blood in stool, and an elongated mass of the upper right quadrant. (Acta Chir Belg 2015;115[5]:327.) Diagnosis is made using CT scan, and it should show the classic “bull's eye” appearance of the affected segment of bowel. (Radiol Med 2015;120[1]:105.) Diagnosis of intussusception can reliably be done through CT, and the imaging is 83.3% sensitive. Other diagnostic tools still being used to identify intussusceptions include plain abdominal x-rays, barium enema, colonoscopy, and ultrasound. (Acta Medica [Hradec Kralove] 2015;58[2]:66.)

A gastrografin enema was performed in this patient, which resolved the intussusception and her symptoms. A pre-operative colonoscopy was performed, and two polyps were biopsied. One was located in the cecum and did not show any hyperplastic or adenomatous changes. The second was biopsied from the transverse colon, and was a tubular adenoma. The patient's previous history is significant for other polyps, none of which showed dysplastic or inflammatory changes.

A right hemicolectomy was performed two days after presentation to the ED to prevent recurrence of the intussusception. Studies have suggested the use of radiologic findings to distinguish idiopathic from secondary intussusception, which may be useful in determining the need for surgery. (Radiol Med 2015;120[1]:105.) The resected segment was 25 cm of the colon beginning from the cecum, with an attached 7 x 1 x 0.9 cm appendix and a 4.5 cm portion of the terminal ileum. The mucosa was pink-tan without masses or ulceration. Interestingly, there was an approximately 2.5 cm intussusception. Typical therapy consists of segmental bowel resection in adults to prevent recurrence and to eliminate an underlying malignancy. (Radiol Med 2015;120[1]:105.) Conversely, intussusception in children is idiopathic in 75 to 90 percent of the cases, and the majority resolve using air or fluid pressures — barium or air enema. (Acta Chir Belg 2015;115[5]:327; J Nat Sci Biol Med 2015;6[1]:208.)

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The Link to Celiac Disease

Intussusception is the most common cause of small bowel obstruction in young children. When signs of bowel obstruction or acute abdomen are present, there is a high clinical suspicion. (Acta Chir Belg 2015;115[5]:327.) Intussusception is a rare discovery in adults, representing five percent of all reported cases and one to five percent of intestinal obstructions. (Korean J Gastroenterol 2013;61[1]:17; Gastroenterology Insights 2012;4[e4]:57.) Several types of intussusception occur along the length of the bowel, but the most common type is ileo-colic, accounting for approximately 90 percent of the cases. (Acta Chir Belg 2015;115[5]:327.)

Intussusception is most often the result of a focal or lead point that forces the bowel to involute into itself, causing a portion of the gut to telescope into the adjacent segment of the bowel. (J Coll Physicians Surg Pak 2013;23[4]:287.) The associated mesentery becomes congested and can result in small bowel obstruction, ischemia, bowel necrosis, or perforation leading to peritonitis and sepsis. (BMJ Case Rep 2014;2014, doi: 10.1136/bcr-2013-203156; Acta Chir Belg 2015;115[5]:327; J Nat Sci Biol Med 2015;6[1]:208.) Lead points include but are not limited to neoplasms, polyps, or Meckel's diverticulum; the former being responsible for 65 to 70 percent of adult cases and the latter being more common in young children. Very few cases of intussusception in adults are idiopathic. The exact mechanism of intussusception varies, but the leading theory suggests that lesions or irritants to the bowel wall can serve as a focus point for the bowel wall to involute on itself with continued peristaltic activity. (Acta Medica [Hradec Kralove] 2015;58[2]:66.)

An interesting association mentioned was the linkage between intussusception and celiac disease. This patient did not display symptoms or have a history of celiac disease upon questioning, but this detail should not be overlooked in other cases because intussusception may be the originating clue to suggest celiac disease. (BMJ Case Rep 2014;2014, doi: 10.1136/bcr-2013-203156.)

This patient's post-operative ileus was resolved by encouraging frequent ambulation. Dietary restrictions were placed until bowel function returned to normal. She was discharged one week later, and was doing well at follow-up.

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