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CASE REPORT
Year : 2017  |  Volume : 6  |  Issue : 3  |  Page : 163-165

Intussusception due to colon carcinoma in a young man: An unusual presentation


Department of Radio Diagnosis, MNR Medical College and Hospital, Sangareddy, Telangana, India

Date of Web Publication25-Sep-2017

Correspondence Address:
Prashanth Mamidipalli
MNR Medical College and Hospital, Sangareddy - 502 294, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_28_17

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  Abstract 

Adult intussusception is a rare disease without classical symptoms. A delay in diagnosis may result in a fatal progression to complete bowel obstruction, ischemia, necrosis, and perforation. The association of a tumor with intussusception in young adults is rare. We report a case concerning a young male without a family history of bowel cancer presenting with a proximal ascending colon intussusception secondary to colonic carcinoma. This case puts insights on how intussusception and possible colon carcinoma must be included in the differential diagnosis even in young adults who have a persistent abdominal complaint. A high index of suspicion and an early computed tomography scan were required to prevent delayed diagnosis and the development of complications.

Keywords: Colon carcinoma, contrast computer tomography scan, intussusception, young man


How to cite this article:
Mamidipalli P, Bakle SM, Narayana B, Reddy P S, Reddy Y P, Devendhar A. Intussusception due to colon carcinoma in a young man: An unusual presentation. J NTR Univ Health Sci 2017;6:163-5

How to cite this URL:
Mamidipalli P, Bakle SM, Narayana B, Reddy P S, Reddy Y P, Devendhar A. Intussusception due to colon carcinoma in a young man: An unusual presentation. J NTR Univ Health Sci [serial online] 2017 [cited 2017 Oct 23];6:163-5. Available from: http://www.jdrntruhs.org/text.asp?2017/6/3/163/215523


  Introduction Top


Adult intussusception is a seemingly rare disease without classical symptoms in adult population. A delay in diagnosis may result in a fatal progression to complications such as complete bowel obstruction, ischemia, necrosis, and perforation. The association of a tumor with intussusception in young adults is rare. We report a case concerning a young male without a family history of bowel cancer presenting with a proximal ascending colon intussusception secondary to colonic carcinoma. This case puts insights on how intussusception and possible colon carcinoma must be included in the differential diagnosis even in young adults who have a persistent abdominal complaint. A high index of suspicion and an early computed tomography (CT) scan were required to prevent delayed diagnosis and the development of complications.


  Case Report Top


A 35-year-old male presented with a 3-month history of intermittent abdominal pain, weight loss, dyspepsia, intermittent fever, and nausea. No history of bloody diarrhea. Initial examination revealed tenderness and a vague mass in the right lower quadrant of the abdomen. He was found to have normocytic normochromic anemia. Abdominal plain radiograph was unremarkable [Figure 1]. Ultrasound scan showed large bowel intussusception. A contrast CT scan was carried out which suggested a large bowel intussusception with a mass lesion [Figure 2]. A right hemicolectomy with ileotransverse anastomosis was performed [Figure 3]. Histology revealed an intussusception around the tumor with moderately differentiated adenocarcinomatous changes, serosal involvement without lymphatic invasion, and appendix is invaded by the tumor (pT4N0Mx). Patient was discharged without complications 10 days after surgery. Molecular analysis was negative for genetic causes.
Figure 1: There is a hyperenhancing nidus acting as a lead point causing intussusception of the proximal ascending colon, note the bowel wall stratification and irregular enhancement proximal to lesion. Appendix is not visualised. Transverse colon appears normal

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Figure 2: Ultrasound scan showing large bowel intussusception with target appearance

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Figure 3: Operative findings show a proximal ascending colon intussusception with a tumor in cecum

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  Discussion Top


Intussusception is an often rare in the adult population characterized by no definite “classical” abdominal symptoms.[1] Adult intussusception accounts for about 5% of all intussusceptions[2],[3],[4] in the Western world but very less in subtropical countries like India. The diagnosis is elusive, and this rare entity needs to be considered in the differential diagnosis of chronic abdominal symptoms in the adult.[1] Colocolic intussusception is the most common type in adults.[5] Common sites of occurrence are the junction between freely mobile segments of bowel and segments that are relatively fixed. Intussusception occurs when a contracted proximal intestinal segment telescopes into the relaxed distal intestinal segment and disturbs normal intestinal peristalsis.[2] The intussuscepted segment later transcends edematous and eventually necrosis and perforation due to compromised blood supply. In adults, the majority of cases have a definite underlying cause, with primary intussusceptions accounting for only 15%-25%[1],[2],[3],[6] for most authors. Any intraluminal lesions can act as lead point, disturbing its normal peristaltic pattern. Polyps are the most commonly implicated lesions (for example, Peutz–Jeghers syndrome), but several other causes have been described including malignant tumors, Meckel's diverticulum, chronic ulcerations, typhoid enteritis,[7] adhesions, worm infestation, endometriosis, mucocele of the appendix, trauma, foreign body, intramural hematomas, previous stoma/anastomotic sites,[1] inspissated stools as in cystic fibrosis,[8] bezoars,[7] and even prolonged fasting.[5] Approximately 50% of colonic lesions are due to malignant vegetative neoplasms.[3],[4],[9],[10] About 24%-25% of the small bowel lesions are malignant.[4],[7] Intussusception has no “classical” abdominal symptoms, and in adults, <20% of cases present acutely.[1] The clinical presentation may include a palpable mass, nausea and vomiting, abdominal colic, change in bowel habit, and occult blood per rectum.[1] Due to the nonspecific nature of these symptoms, the diagnosis is usually delayed. In adults, total obstruction is rare which may account for its chronic symptomatology, whereas in children, strangulation and gangrene are inevitable features. Spontaneous sloughing of the ischemic intussuscepted colonic segment has been reported in the literature.[3],[4],[11]

Plain abdominal radiographs are of limited diagnostic value in an adult. Barium enema and ultrasound which are often useful for diagnosis and therapy in children are less helpful in adults. The role of hydrostatic reduction with barium enema remains controversial in adults. Intraluminal seeding or venous embolization of malignant cells can occur with this procedure.[6] Contrast CT scan is the primary diagnostic tool of choice as it confirms the diagnosis and may identify the underlying cause.[3],[10] Surgical resection is the definitive treatment for the invaginating tumor. It is important for the surgeon to take into consideration the clinical status, location and status of the intussusception, and condition of the bowel before deciding on whether a primary anastomosis should be performed.[9],[10] Furthermore, manual reduction of the intussusception is not advocated during laparotomy.[1],[4],[9],[12] It is interesting to note that the intussusception caused by the carcinoma in our patient probably resulted in him being diagnosed at a favorable early stage of his disease. Initial investigation by abdominal radiograph is unremarkable and ultrasound scan reported large bowel intussusception, and definite findings were obtained on contrast CT scan which are comparable to surgical findings.


  Conclusion Top


Intussusception in young adult is rare and potentially life-threatening condition. A high index of suspicion and an early CT scan may prevent delayed diagnosis and the development of complications. This case puts insights on how intussusception and possible colon carcinoma must be included in the differential diagnosis even in young adults who have persistent abdominal complaints.

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Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Gordon RS, O'Dell KB, Namon AJ, Becker LB. Intussusception in the adult – A rare disease. J Emerg Med 1991;9:337-42.  Back to cited text no. 1
    
2.
te Strake L. Intussusception in adults. Diagn Imaging 1980;49:15-22.  Back to cited text no. 2
    
3.
Schuind F, Van Gansbeke D, Ansay J. Intussusception in adults – Report of 3 cases. Belg Surg J 1985;85:55-60.  Back to cited text no. 3
    
4.
Weilbaecher D, Bolin JA, Hearn D, Ogden W 2nd. Intussusception in adults. Review of 160 cases. Am J Surg 1971;121:531-5.  Back to cited text no. 4
    
5.
Winslet MC. Intestinal obstruction. In: Russell RC, Williams NS, Christopher JK, editors. Bulstrode: Bailey and Love's Short Practice of Surgery. 24th ed. UK: Oxford University of Press; 2000. p. 1194-7.  Back to cited text no. 5
    
6.
Jasmi AY, Zain AR, Hayati AR. Large bowel cancer in a young adult presenting as an acute intussusception – A case report. Med J Malaysia 1992;47:316-9.  Back to cited text no. 6
    
7.
Jones PF. Acute abdomen: Obstruction and haemorrhage. In: O'Higgins NJ, Chisholm GD, Williamson RC, editors. Surgical Management. 2nd ed. Somerset U.K.: Butterworth & Heinemann; 1991. p. 367.  Back to cited text no. 7
    
8.
Albanese CT, Norton JA, Bollinger RR, Chang AE, Lowry SF, Mulrihill SJ, et al. Surgery – Basic Science and Clinical Evidence. New York: Springer Verlag; 2001. p. 2080-1.  Back to cited text no. 8
    
9.
Lorenzi M, Iroatulam AJ, Vernillo R, Banducci T, Mancini S, Tiribocchi A, et al. Adult colonic intussusception caused by malignant tumor of the transverse colon. Am Surg 1999;65:11-4.  Back to cited text no. 9
    
10.
d'Silva KJ, Dwivedi AJ, Shetty A, Prakash S. An unusual presentation of colon cancer in a young individual. Dig Dis Sci 2005;50:1033-5.  Back to cited text no. 10
    
11.
Smith IS, Gillespie G. Adult intussusception in Glasgow. Br J Surg 1968;55:925-8.  Back to cited text no. 11
    
12.
Felix EL, Cohen MH, Bernstein AD, Schwartz JH. Adult intussusception; Case report of recurrent intussusception and review of the literature. Am J Surg 1976;131:758-61.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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