Report of an unusual case of ileoceacal intussusception in an adult due to tuberculosis and review of the literature

Abstract

Ileocecal intussusception in an adult is a rare clinical entity. Intussusception, when it occurs in adult, is usually associated with underlying pathologic condition. Here, we present a case of an adult presented with chronic intussusception diagnosed by computed tomography scan, managed by right hemicolectomy and found to have underlying tuberculosis as a cause on histopathology.

Keywords: Intestinal resection, intussusception, tuberculosis

How to cite this article:
Vaibhav K S, Anand H T. Report of an unusual case of ileoceacal intussusception in an adult due to tuberculosis and review of the literature. Ann Trop Med Public Health 2014;7:231-3
How to cite this URL:
Vaibhav K S, Anand H T. Report of an unusual case of ileoceacal intussusception in an adult due to tuberculosis and review of the literature. Ann Trop Med Public Health [serial online] 2014 [cited 2020 Aug 11];7:231-3. Available from: https://www.atmph.org/text.asp?2014/7/5/231/154827
Introduction

Intussusception, in the adult population, is a very rare occurrence. Although 90% of cases of pediatric intussusceptions are idiopathic, a demonstrable etiology is found in 70-90% of adult cases. [1] Adult patients with ileococlic intussusceptions have underlying neoplasm either benign or malignant as an etiological factor. Though adult patients usually present with chronic abdominal pain with or without vomiting, the classic triad of vomiting, abdominal pain and cherry colored stool is found in some patients. [2] Computed tomography (CT) scan is the investigation of choice. Surgical treatment with resection of the involved segment without any attempt of reduction is the standard treatment. Although few cases have been reported, ileocolic tuberculosis presenting as intussusception is a very rare occurrence.

Case Report

A 30-year-old male patient presented with abdominal pain, vomiting and constipation. He was having history of decreased appetite and weight loss. Patient did have on and off abdominal pain in the past for which he was doing self-medication. Patient was tobacco chewer for consecutive 3 years. Family history was of no significance. On examination, he was found to have distension of abdomen and feeble peristalsis. Biochemical investigations were as follows: Hemoglobin -11.7 g/dL, total white blood cell count -5,250/cmm, random blood sugar -110 g/dL, serum creatinine -0.86 mg/dL, serum bilirubin -0.5 mg/dL, alanine aminotransferase -13 units/L, aspartate aminotransferase -20 units/L, alkaline phosphatise -93 units/L. Ultrasonography was suggestive of dilated small bowel loops with rest of the abdomen was unremarkable. Upright abdominal X-ray was showing air fluid levels with absence of gas in colon. On CT examination, typical claw hand appearance was seen suggestive of ileocecal intussussception [Figure 1]. Patient was operated for right hemicolectomy with ileotrasverse anastomosis [Figure 2]. Lymphnodes along the root of mesentery sampled and sent along with specimen for histopathological examination. Histopathological examination was suggestive of caseating granulomatous inflammation involving the specimen and lymphnodes [Figure 3]. Postoperative outcome of patient was uneventful. He was discharged 5 days after surgery. Patient was placed on isoniazid, rifampicin, ethambutol, and pyrizinamide for 2 months, followed by isoniazid and rifampicin for 4 months. After 1½ month follow-up, patient gained 3 kg weight. At 6 months follow-up, patient was healthy with 10 kg weight gain.

Figure 1: Computed tomography scan image showing classical “claw sing” suggestive of ileocolic intussusception

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Figure 2: Operative photograph showing invaginating ileum in to ceacum

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Figure 3: Histopathological slide showing classical granulomatous infl ammation with presence of Langerhan’s giant cells suggestive of tuberculosis

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Discussion

Intissusception is defined as telescoping of the proximal part of the gastrointestinal tract into adjacent distal part leading to impaired peristalsis, obstruction and possible vascular compromise. Intussusception is a common clinical entity in pediatric patients presenting with intestinal obstruction whereas it is a diagnosis of exclusion in adults. In adults, intussusception is a rare occurrence estimating only 5% of all cases of intussusceptions across all ages and 1-5% of all cases of intestinal obstruction. Primary intussusceptions account for 8-20% of cases. [3],[4] Secondary intussusception, a common phenomenon in adults, is usually associated with a pathological condition involving a lead point. This causes one section of bowel along with its mesentery to prolapse into adjacent bowel causing intestinal obstruction and possible vascular compromise leading to ischemia. Although male have a high propensity to develop intussusception in the pediatric population, incidence of intussusception is equal in both genders in adults. [5] Intussusceptions involving a small intestine are usually the result of benign such as inflammatory polyp, liomas, Meckel’s diverticulum and adhesions, [6],[7] while malignant neoplasms usually adenocarcinomas are the common causes of ileocolic and colocolic intussusception. [8]

Abdominal tuberculosis is still a major health problem in many parts of the world. Even in developed countries, incidence has been steadily increasing due to AIDS epidemic, transglobal migration and increased number of immunosupressed patients. Abdominal tuberculosis continues to be a major diagnostic dilemma in non-HIV patients presenting nonspecific abdominal symptoms. Due to lack of specific symptoms and signs of intestinal tuberculosis, most patients present with complications like intestinal perforation or obstruction or even fistula formation. Still, intussusception as a presentation of intestinal tuberculosis is a very rare event. Inflammatory adhesions around the ileocecal region might be the probable reason for intussusception in our case.

In sharp contrast to their pediatric counterpart, adult intussusception requires surgery. [9] Cross-scarring between intussusceptum and intussuscipiens may not allow successful pneumatic or hydrostatic reduction. In addition, lesion at the apex may miss detection. Though intussusception carries a very good prognosis, decisive prognostic factor is the nature of pathology leading to process. [10]

To conclude, adult ileocolic intussusception due to tuberculosis should be kept in mind in patients presenting with chronic abdominal pain. CT scan is the investigation of choice with surgical resection of the involved segment being the primary treatment.

References
1.
Yakan S, Caliskan C, Makay O, Denecli AG, Korkut MA. Intussusception in adults: Clinical characteristics, diagnosis and operative strategies. World J Gastroenterol 2009;15:1985-9.
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Begos DG, Sandor A, Modlin IM. The diagnosis and management of adult intussusception. Am J Surg 1997;173:88-94.
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Azar T, Berger DL. Adult intussusception. Ann Surg 1997;226: 134-8.
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Piñero Madrona A, Ríos Zambudio A, Castellanos Escrig G, Carrasco Prats M, Parrilla Paricio P. Intestinal invagination in the adult. Gastroenterol Hepatol 1998;21:398-400.
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Rathore MA, Andrabi SI, Mansha M. Adult intussusception – A surgical dilemma. J Ayub Med Coll Abbottabad 2006;18:3-6.
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Erbil Y, Eminoglu L, Calis A, Berber E. Ileocolic invagination in adult due to caecal carcinoma. Acta Chir Belg 1997;97:190-1.
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Alkim C, Sasmaz N, Alkim H, Caglikülekçi M, Turhan N. Sonographic findings in intussusception caused by a lipoma in the muscular layer of the colon. J Clin Ultrasound 2001;29:298-301.
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Nagorney DM, Sarr MG, McIlrath DC. Surgical management of intussusception in the adult. Ann Surg 1981;193:230-6.
9.
Desai N, Wayne MG, Taub PJ, Levitt MA, Spiegel R, Kim U. Intussusception in adults. Mt Sinai J Med 1999;66:336-40.
10.
Huang WS, Changchien CS, Lu SN. Adult intussusception: A 12-year experience, with emphasis on etiology and analysis of risk factors. Chang Gung Med J 2000;23:284-90.

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1755-6783.15482

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[Figure 1], [Figure 2], [Figure 3]

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