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CASE REPORT

Treatment of Adult Intussusception with Non-operative Management:

A case report

Shahrul Rahman1, Muhammad Al Anas2

1
Department of Internal Medicine, Faculty of Medicine, University of Muhammadiyah Sumatera Utara,
Medan, Indonesia
2
Faculty of Medicine, University of Muhammadiyah Sumatera Utara, Medan, Indonesia

Correspondence email: shahrulrahman@umsu.ac.id

Abstract: Intussusceptions, defined as insertion of proximal part of intestine into distal one, it is
the second most common acute abdomen pathology after appendicitis. Acute intussusception is
one of the common causes of acute intestinal obstruction in children, but on seldom occasions
associated with leading points to the intussusceptions. The symptoms are the result of
intussusception, like intestinal obstruction, volvulus due to subserosa lipoma and hemorrhage
due to ulcerations of the overlying mucosa caused by direct pressure from the lipoma or the
intussusception itself. Intussusception in adults is very rare. Most intussusception cases must be
treated surgically. In patients who present with a vague history and constellation of abdominal
symptoms pointing towards obstruction and are found to have a short segment intussusception, it
is a valid option to apply a conservative approach with caution. Based on the available literature,
CT scan evaluation seems to have both diagnostic and prognostic value, as it provides enough
evidence with regards to signs indicating the need for surgery. Herewith, we describe a rare case
of intussusception in Indonesian adult which was successfully treated non-surgically.
Keywords : intussusception, obstruction, non-surgically

INTRODUCTION usually has history of more than 14 days, 2 is

Intussusceptions, defined as insertion rare in childhood, commonly associated with
of proximal part of intestine into distal one, leading points as neoplasm and other
it is the second most common acute pathology.3 It is rare to find the triad of
abdomen pathology after appendicitis.1 acute intussusceptions, colicky intermittent
Acute intussusception is one of the common abdominal pain, vomiting, and bloody stool
causes of acute intestinal obstruction in in chronic intussusceptions.4
children, but on seldom occasions associated Acute intussusceptions as a clinical
with leading points to the intussusceptions. entity is poorly recognized and rarely
While chronic intussusceptions, which included in the differential diagnosis of

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prolonged abdominal symptoms and physical examination showed no

faltering growth as reported in some abnormalities.
studies.4 It is frequently associated with a The patient was treated with
high rate of unsuccessful hydrostatic intravenous administration of a sorbitol
reductions. This makes an early surgical solution30-drips/minute and proton-pump
intervention advisable.5 inhibitor injection (lansoprazole 30 mg/day).
Most pediatric ileocolic The following investigations were
intussusceptions are idiopathic. In adults and performed: laboratory findings showed
occasionally in children over 2 years of age, increased leukocytes of 12.71x103/uL,
a pathologic lead point for intussusception monocytes of 10% and low lymphocytes of
can be found.2 In children, the incidence of 17.39%. He had a normal renal function.
identifiable lead point in pediatric Electrolyte test was normal. The plain
intussusception has been reported as 1.5- abdominal x-ray showed an abdominal
12.0%. Underlying pathological causes of distension by increased air distribution in
intussusception can be identified in 1.5- intestine, and air fluid level showed. We can
12.0% of cases.6 These include Meckel's concluded the case as ileus buy using the
diverticulum, polyps, duplications, plain abdominal X-ray (Figure 1).
mesentery cysts, intestinal hematoma and
lymphoma.7
As stated above, the management of
intussusception in general is to perform
surgery. We report this case because of the
successful non-surgical management of
intussusception. Herewith, we describe a
rare case of intussusception in Indonesian
adult reported.

CASE
A 32-year-old man presented with Figure 1. Plain abdominal x-ray shows an abdominal
distension by increased air distribution in intestine, and air
acute abdominal pain for three days at a
fluid level showed.
general hospital. He also complained nausea,
and vomiting for a week. The patient had no We added amino acids in dextrose
fever, no change in stool frequency and solution for intravenous infusion 1000
consistencies, or any other illnesses. He only mL/24 hour by turns with sorbitol solutions.
consumed prescribed medication from We also replaced proton-pump inhibitor
hospital to treat the pain. injection with histamine H2-receptor
On physical examination, we found a antagonist injection (ranitidine 50 mg/12
normo-weight patient with normal vital hours). We also added metoclopramide
signs. Beside mild epigastric pain on injection 10 mg/24 hours. Patient received
palpation, the increase peristaltic in injection of intravenous antibiotics with
auscultation was found. The rest of his ceftriaxone 1 gr/24 hours, and steroids with
dexamethasone injection 5 mg/24 hours.

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We decided to perform a computed The symptoms are the result of

tomography (CT) scan of the abdomen with intussusception, such as intestinal
contrast. In order to perform the procedure, obstruction, volvulus due to subserosa
the patients were given bowel preparation. lipoma and hemorrhage due to ulcerations of
The CT scan were performed in the second the overlying mucosa caused by direct
day of hospitalization while after the pressure from the lipoma or the
procedure, the treatments were continued. intussusception itself.12 In contrast to the
The CT scan was performed in second day, acute presentation of childhood
and the result showed mild liver intussusception, the adult type usually has a
enlargement with sharp edges, and in colon subacute or chronic onset. Less than 20%
area there was increased distribution of air. present with acute bowel obstruction.
The patient was free of all the original A palpable abdominal mass is present
symptoms by the fifth day after in only 7%–42% of the cases.13 Intermittent
hospitalization. After that, the patient was intussusception due to the lipoma may cause
able to return back home. non-specific symptoms and carry a further
challenge for diagnosis.
DISCUSSION In adults, intussusception usually
Intussusception in adults is very rare presents with intermittent abdominal pain,
with an incidence of two to three cases per nausea, vomiting, constipation, melena or
population of 1,000,000 per year.8 When it is even weight loss. In our case report, the
found in adults, the cause is usually patient had a very mild clinical symptoms.
secondary to a pathologic lead point within The laboratory findings showed an increased
the bowel due to altered normal peristaltic level of leukocytes and our patient also
movements.9 described similar unspecific symptoms. In
The limitation in this report is we the literature, occult hemorrhage and
didn’t further perform an examination to intermittent intussusceptions are the most
find the cause. Lipomasare more common in frequent clinical findings.13,14
the colon (75%) than in the small intestine The psychiatric background of the
(<25%). They are the second most common patient in our case report made the
benign small bowel tumors after interpretation of the clinical findings
leiomyomas. Their usual localization in the difficult and might delay the diagnostic tests.
small bowel is the ileum in 50% of the The information of colic pain and altered
cases. The peak age of disease is in the sixth stool, the presence of appetite but fear of
to seventh decade of life. They originate in eating because of vomiting, pain and the
the submucosa in 90% of the cases and anemia were reasons for the CT of the
usually are solitary (85%–89%). Size may abdomen for further examination.
range from 1 to 30 cm. Usually, Preoperative diagnosis is difficult due to the
asymptomatic but they can give rise to variability of the clinical presentation. CT
symptoms related to their size and scan is the imaging of choice radiological
localization. A total of 75% of those greater finding is a mass lesion, representing a
than 4 cm are symptomatic.10,11 thickened segment of the bowel and the
tumor with low density equal to fat. CT scan

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can also give indirect signs of bowel All patients need to be observed for
ischemia like free fluid and fluid or gas progression or regression of their clinical
collection in the intestinal wall. CT scan has pictures in order to avoid potential
a specificity of 100% and sensitivity of up to complications such as ischemia, and
87% in adults.15 potential necrosis of the affected bowel
In our case, CT scan showed the segment. For patients presenting a vague
atypical characteristics of invagination with clinical picture and symptoms at the time of
no further complications after the admission, short intussusception length on
medicaments were given. The localization of imaging studies, simultaneous nature of
intussusception in the gastrointestinal tract is intussusceptions in different locations, and
also important: colo-colonic intussusception the absence of a lead point in the
is >70% caused by a malignancy.10,11 pathogenesis based on follow-up imaging
Neoplasia is also a leading lesion in 57% in studies, conservative management is
the small bowel but malignancy here is less appropriate, albeit with caution. If the
frequent (30%). Seventy percent of adult patients had developed signs of obstruction,
small intestine intussusception is caused by bowel ischemia or necrosis, exploratory
benign entities.13 In our case report, the fatty surgery is indicated.17,18
lesion was located in the terminal ileum. No
pathologic lymph nodes were detected in the CONCLUSION
CT scan. In patients who present with a vague
In the literature, there is no consensus history and constellation of abdominal
on safety and efficacy of laparoscopy symptoms pointing towards obstruction and
application in adult intususception.16 In the are found to have a short segment
present case, we selected non-operative intussusception, it is a valid option to apply
managements for the following reasons: the a conservative approach with caution. Based
patients clinical condition was good. on the available literature, CT evaluation
Clinically and radiologically, the bowel was seems to have both diagnostic and
not distended too much so that an prognostic value, as it provides enough
observation and non-operative approach was evidence with regards to signs indicating the
still possible and safe. There were no signs need for surgery.
of ischemia of the bowel segment. Except an If exam and CT findings, as described
open appendectomy, patient did not undergo earlier, hint or point towards a self-limiting
previous surgery; thus, the possibility of intussusception, then conservative
intra-abdominal adhesions was low. Intra- management with caution is appropriate
operatively, the affected bowel segment of with serial abdominal exams, bowel rest, IV
our patients appeared short with a mild fluids, and appropriate labs on an as needed
image of an ileus. There are other case basis, along with a follow-up imaging
reports described that an open surgery was studies to assess the etiology and the status
necessary because preoperative findings of the intussusceptions. In recurrent cases,
suggested the necessity of large resection further GI evaluation is warranted.
such as hemicolectomy.16 With this conservative approach and in
the light of absence of evidence of other

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coexisting pathologies, an emergent Invagination and Acute Appendicitis. J

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indecision making, surgical planning, and 7. Kotha VK, Khandelwal A, Shanboque
treatment. AK, et al. Radiologist's perspective for
the Meckel's diverticulum and its
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