Small bowel intussusception causing a postoperative bowel obstruction following laparoscopic low anterior resection in an adult Ahmad S. Hussain, MD, Rajalakshmi Warrier, MD, and Harry T. Papaconstantinou, MD
Adult intussusception usually presents with nonspecific symptoms such as abdominal pain, bloating, nausea, vomiting, and a change in bowel habits. Although postoperative intussusception has been described in the pediatric population, there has been little description of it in the adult population. Postoperative intussusception has unique challenges, as hydrostatic reduction may compromise bowel anastomoses. Surgery is the universal treatment in these patients. In adults, delay in diagnosis and definitive treatment may be a direct result of common symptomatology between postoperative ileus and intussusception. We present a case of an adult patient who underwent laparoscopic low anterior resection for rectal cancer and developed a small bowel intussusception causing obstruction requiring surgery. To our knowledge, this is the first report of a small bowel intussusception masquerading as a postoperative ileus in an adult. While most postoperative delayed bowel function is attributed to ileus, abscess formation, or anastomotic leak, other uncommon etiologies, including intussusception, may occur and are important to include in the differential diagnosis.
ntestinal intussusception is a relatively common abdominal emergency in children; however, the incidence of intussusception in adults is rare and represents less than 5% of all cases (1). In adults, transient asymptomatic enteric intussusception is often noted on imaging and resolves spontaneously without any treatment (2). Complete and persistent small bowel obstruction secondary to intussusception is less common and is usually associated with a lead point lesion (1). Adult intussusception usually presents with nonspecific symptoms such as abdominal pain, bloating, nausea, vomiting, and a change in bowel habits. The abdominal exam is often unremarkable, which contributes to an error or delay in diagnosis. In children, initial attempts at reduction of the intussusception with barium or air are often suggested, but in adults surgery is the definitive treatment (3). Postoperative intussusception has unique challenges, as hydrostatic reduction may compromise bowel anastomoses (4). In adults, delay in diagnosis and definitive treatment may be a direct result of common symptomatology between postoperative ileus and intussusception. We present a case of an adult patient
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who underwent laparoscopic low anterior resection for rectal cancer and developed a small bowel intussusception causing obstruction. CASE REPORT A 75-year-old man with chronic obstructive pulmonary disease with bronchiectasis, coronary artery disease, and hypertension underwent a single-incision laparoscopic low anterior resection for recurrent rectal cancer. Nonsteroidal antiinflammatory drugs were not utilized for pain control. Postoperatively, he had persistent abdominal bloating, nausea, and emesis. Examination revealed a hypertympanic distended abdomen without signs of peritonitis. A computed tomography (CT) scan of the abdomen and pelvis disclosed a significantly dilated colon and small bowel with no signs of obstruction. The bowel gas pattern was consistent with a postoperative ileus. The patient was initiated on total parenteral nutrition. His condition thereafter progressively improved with reduced abdominal distention. His bowel function eventually returned, an enteral diet was advanced as tolerated, and he was sent home on postoperative day 20 on a regular diet. Two days after discharge, the patient returned to the hospital with obstipation, mild abdominal bloating, and emesis. CT scan demonstrated an ileoileal intussusception causing a highgrade small bowel obstruction (Figure 1). Nasogastric tube decompression and intravenous fluids were initiated, and the patient continued to have signs of bowel obstruction. At operation, he was found to have a small bowel intussusception with fibrous bands holding the telescoped bowel in place (Figure 2). He underwent a small bowel resection and primary anastomosis without
From the Department of Surgery (Hussain, Warrier, Papaconstantinou), Section of Colon and Rectal Surgery (Warrier), Scott & White Memorial Hospital and Clinic and Texas A&M University System Health Science Center College of Medicine, Temple, TX. Corresponding author: Harry T. Papaconstantinou, MD, Associate Professor and Interim Chairman, Department of Surgery, Scott & White Memorial Hospital and Clinic, 2401 South 31st Street, Temple, TX 76508 (e-mail: hpapaconstantinou@ sw.org).
Proc (Bayl Univ Med Cent) 2014;27(2):128–130
DISCUSSION Postoperative intussusception in adults is an uncommon but significant cause of small bowel obstruction. Although it has been previously described in the pediatric population (Table) (4–12), to our knowledge this is the first report of a small bowel intussusception masquerading as a postoperative ileus in an adult. Whereas the time from surgery to diagnosis appears to average about 1 week c d for children, for our patient the diagnosis was made 22 days after surgery. This delay was likely due to a lower index of suspicion in an adult patient. Diagnosis of postoperative intussusception is difficult and is often made by ultrasound, contrast radiograph, or intraoperative findings in children (Table). In adults, ileus is a far more common postopFigure 1 (a–d). CT scan at readmission showing a high-grade small bowel obstruction with a transition zone at a erative morbidity, presenting with symptoms similar to obstruction, region of ileoileal intussusception. Notice the telescoping of the small bowel (arrow) causing a bowel obstruction. including nausea, vomiting, abdominal distention, and obstipadifficulty. Final pathology revealed benign mucosa with scattion (13). Further complicating the clinical picture in these tered reactive lymphoid aggregates, vascular congestion, patients is postoperative narcotics masking symptoms and focal acute serositis, fibrous adhesions, and gross evidence reliable physical exams (5) and the known negative effects of small bowel telescoping. Postoperatively, total parenteral of opiates on intestinal peristalsis (14). Postoperative ileus nutrition was initiated to aid in nutrition, and his enteral usually lasts on average 3 to 5 days, but can last much diet was advanced. The patient regained normal bowel funclonger (15). tion, and follow-up imaging showed no obstruction or other In adults, CT scan is frequently used for postoperative evaluabnormality. ation of patients with bowel obstruction and can be effective in diagnosing postoperative ileus; however, given the transient nature of intussusception, the CT scan must be obtained at the time of discomfort, as spontaneous reduction may occur between episodes. CT enteroclysis is a reliable diagnostic tool for diagnosing small bowel intussusception (16) but has not been documented as a reliable tool to reduce intussusception, with recurrence of the intussusception described (17). CT evidence of intussusception includes a target or sausage-shaped mass (18), as shown in Figure 1. The transient nature of the pathology is likely the reason we did not identify the intussusception earlier in our patient. Postoperative intussusception in children is frequently treated by exploration and manual reduction (Table). We chose to operate at the time of diagnosis and resect the intussuscepted bowel, as we were concerned about the etiology and pathology of the lead point in this patient with a known cancer. In adults, the lead point has a higher likelihood of Figure 2. Intraoperative finding of the ileoileal intussusception. Notice the being malignant. In our patient, the final pathology showed proximal intussusceptum on the left telescoped circumferentially into the distal intussuscipiens. a benign lead point. a
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Table. Literature review of postoperative intussusception Author (reference)
Year
N
Age
Diagnostic modality
Time from surgery to diagnosis
Treatment
Ein et al (5)
1982
10
Children (2 m–15 y)
100% IO
8–39 days
70% MR 30% RR
West et al (6)
1988
36
Children (1 m–18 y)
86% XR 14% IO
Avg 8 days (1–24 days)
8% HR 81% MR 11% RR
Olcay et al (7)
1989
10
Children (3 m–10 y)
–
3–8 days
90% MR 10% RR
Velin et al (8)
1992
2
Children (6 m–12 m)
–
3–5 days
100% MR
Linke et al (4)
1998
5
Children
80% US 20% IO
5 days–3 months
100% MR
Kidd et al (9)
2000
5
Children
80% UGI SBFT 20% IO
Avg 7 days
100% MR
Niu et al (10)
2005
14
Children
7% US 93% IO
Avg 4 days (
Adult intussusception usually presents with nonspecific symptoms such as abdominal pain, bloating, nausea, vomiting, and a change in bowel habits. Although postoperative intussusception has been described in the pediatric population, there has been little description of it in the adult population. Postoperative intussusception has unique challenges, as hydrostatic reduction may compromise bowel anastomoses. Surgery is the universal treatment in these patients. In adults, delay in diagnosis and definitive treatment may be a direct result of common symptomatology between postoperative ileus and intussusception. We present a case of an adult patient who underwent laparoscopic low anterior resection for rectal cancer and developed a small bowel intussusception causing obstruction requiring surgery. To our knowledge, this is the first report of a small bowel intussusception masquerading as a postoperative ileus in an adult. While most postoperative delayed bowel function is attributed to ileus, abscess formation, or anastomotic leak, other uncommon etiologies, including intussusception, may occur and are important to include in the differential diagnosis.
ntestinal intussusception is a relatively common abdominal emergency in children; however, the incidence of intussusception in adults is rare and represents less than 5% of all cases (1). In adults, transient asymptomatic enteric intussusception is often noted on imaging and resolves spontaneously without any treatment (2). Complete and persistent small bowel obstruction secondary to intussusception is less common and is usually associated with a lead point lesion (1). Adult intussusception usually presents with nonspecific symptoms such as abdominal pain, bloating, nausea, vomiting, and a change in bowel habits. The abdominal exam is often unremarkable, which contributes to an error or delay in diagnosis. In children, initial attempts at reduction of the intussusception with barium or air are often suggested, but in adults surgery is the definitive treatment (3). Postoperative intussusception has unique challenges, as hydrostatic reduction may compromise bowel anastomoses (4). In adults, delay in diagnosis and definitive treatment may be a direct result of common symptomatology between postoperative ileus and intussusception. We present a case of an adult patient
I
128
who underwent laparoscopic low anterior resection for rectal cancer and developed a small bowel intussusception causing obstruction. CASE REPORT A 75-year-old man with chronic obstructive pulmonary disease with bronchiectasis, coronary artery disease, and hypertension underwent a single-incision laparoscopic low anterior resection for recurrent rectal cancer. Nonsteroidal antiinflammatory drugs were not utilized for pain control. Postoperatively, he had persistent abdominal bloating, nausea, and emesis. Examination revealed a hypertympanic distended abdomen without signs of peritonitis. A computed tomography (CT) scan of the abdomen and pelvis disclosed a significantly dilated colon and small bowel with no signs of obstruction. The bowel gas pattern was consistent with a postoperative ileus. The patient was initiated on total parenteral nutrition. His condition thereafter progressively improved with reduced abdominal distention. His bowel function eventually returned, an enteral diet was advanced as tolerated, and he was sent home on postoperative day 20 on a regular diet. Two days after discharge, the patient returned to the hospital with obstipation, mild abdominal bloating, and emesis. CT scan demonstrated an ileoileal intussusception causing a highgrade small bowel obstruction (Figure 1). Nasogastric tube decompression and intravenous fluids were initiated, and the patient continued to have signs of bowel obstruction. At operation, he was found to have a small bowel intussusception with fibrous bands holding the telescoped bowel in place (Figure 2). He underwent a small bowel resection and primary anastomosis without
From the Department of Surgery (Hussain, Warrier, Papaconstantinou), Section of Colon and Rectal Surgery (Warrier), Scott & White Memorial Hospital and Clinic and Texas A&M University System Health Science Center College of Medicine, Temple, TX. Corresponding author: Harry T. Papaconstantinou, MD, Associate Professor and Interim Chairman, Department of Surgery, Scott & White Memorial Hospital and Clinic, 2401 South 31st Street, Temple, TX 76508 (e-mail: hpapaconstantinou@ sw.org).
Proc (Bayl Univ Med Cent) 2014;27(2):128–130
DISCUSSION Postoperative intussusception in adults is an uncommon but significant cause of small bowel obstruction. Although it has been previously described in the pediatric population (Table) (4–12), to our knowledge this is the first report of a small bowel intussusception masquerading as a postoperative ileus in an adult. Whereas the time from surgery to diagnosis appears to average about 1 week c d for children, for our patient the diagnosis was made 22 days after surgery. This delay was likely due to a lower index of suspicion in an adult patient. Diagnosis of postoperative intussusception is difficult and is often made by ultrasound, contrast radiograph, or intraoperative findings in children (Table). In adults, ileus is a far more common postopFigure 1 (a–d). CT scan at readmission showing a high-grade small bowel obstruction with a transition zone at a erative morbidity, presenting with symptoms similar to obstruction, region of ileoileal intussusception. Notice the telescoping of the small bowel (arrow) causing a bowel obstruction. including nausea, vomiting, abdominal distention, and obstipadifficulty. Final pathology revealed benign mucosa with scattion (13). Further complicating the clinical picture in these tered reactive lymphoid aggregates, vascular congestion, patients is postoperative narcotics masking symptoms and focal acute serositis, fibrous adhesions, and gross evidence reliable physical exams (5) and the known negative effects of small bowel telescoping. Postoperatively, total parenteral of opiates on intestinal peristalsis (14). Postoperative ileus nutrition was initiated to aid in nutrition, and his enteral usually lasts on average 3 to 5 days, but can last much diet was advanced. The patient regained normal bowel funclonger (15). tion, and follow-up imaging showed no obstruction or other In adults, CT scan is frequently used for postoperative evaluabnormality. ation of patients with bowel obstruction and can be effective in diagnosing postoperative ileus; however, given the transient nature of intussusception, the CT scan must be obtained at the time of discomfort, as spontaneous reduction may occur between episodes. CT enteroclysis is a reliable diagnostic tool for diagnosing small bowel intussusception (16) but has not been documented as a reliable tool to reduce intussusception, with recurrence of the intussusception described (17). CT evidence of intussusception includes a target or sausage-shaped mass (18), as shown in Figure 1. The transient nature of the pathology is likely the reason we did not identify the intussusception earlier in our patient. Postoperative intussusception in children is frequently treated by exploration and manual reduction (Table). We chose to operate at the time of diagnosis and resect the intussuscepted bowel, as we were concerned about the etiology and pathology of the lead point in this patient with a known cancer. In adults, the lead point has a higher likelihood of Figure 2. Intraoperative finding of the ileoileal intussusception. Notice the being malignant. In our patient, the final pathology showed proximal intussusceptum on the left telescoped circumferentially into the distal intussuscipiens. a benign lead point. a
April 2014
b
Small bowel intussusception causing a postoperative bowel obstruction
129
Table. Literature review of postoperative intussusception Author (reference)
Year
N
Age
Diagnostic modality
Time from surgery to diagnosis
Treatment
Ein et al (5)
1982
10
Children (2 m–15 y)
100% IO
8–39 days
70% MR 30% RR
West et al (6)
1988
36
Children (1 m–18 y)
86% XR 14% IO
Avg 8 days (1–24 days)
8% HR 81% MR 11% RR
Olcay et al (7)
1989
10
Children (3 m–10 y)
–
3–8 days
90% MR 10% RR
Velin et al (8)
1992
2
Children (6 m–12 m)
–
3–5 days
100% MR
Linke et al (4)
1998
5
Children
80% US 20% IO
5 days–3 months
100% MR
Kidd et al (9)
2000
5
Children
80% UGI SBFT 20% IO
Avg 7 days
100% MR
Niu et al (10)
2005
14
Children
7% US 93% IO
Avg 4 days (
