Intussusception as a Cause of Bowel… Aminde L.

N et al 181

CASE REPORT

INTUSSUSCEPTION AS A CAUSE OF BOWEL OBSTRUCTION IN

ADULTS FROM A RESOURCE LIMITED AREA, CAMEROON

Aminde L.N1, Bonko N.M2, Takah N.F3, Awungafac G3, Teno D4

ABSTRACT
BACKGROUND: Intussusception refers to the telescoping of a proximal segment of bowel into a distal
segment. It is a rare cause of intestinal obstruction in adulthood.
CASE DETAILS: We report two cases of adult intussusception in a post-operative period following
Caesarean Section (with no lead point) and Appendicectomy (due to colonic adenocarcinoma)
respectively.
CONCLUSION: Though rare in adulthood, intussusception should be considered as a differential
diagnosis to bowel obstruction in adults even in the post-operative period.
KEYWORDS: Adult intussusception, Aetiology, post-operative intestinal obstruction, colonic
adenocarcinoma, Cameroon
DOI: http://dx.doi.org/10.4314/ejhs.v25i2.11

INTRODUCTION A 28 years old Seamstress admitted as an

emergency case presenting with a week’s history
Intussusception refers to the invagination or of colicky abdominal pain of increasing severity,
telescoping of a proximal segment of bowel vomiting and abdominal distension. Her stools had
(intussusceptum) into a distal bowel segment a very small volume, were semi-formed and
(intussuscipiens). It is sometimes possible for the contained no blood. In the last 2 months, she
distal segment to invaginate into the proximal reported having suffered from intermittent crampy
segment (retrograde intussusception) (1). This is a abdominal pain and vomiting, which started four
common cause of intestinal obstruction in children weeks after a term uneventful Caesarean Section.
occurring commonly in terminal ileum due to She had lost weight but had no fever. She was
lymphoid hyperplasia following viral infections. It admitted to a hospital for these complaints for
generally presents with crampy abdominal pain, which she was managed for a functional colopathy
bloody diarrhoea (red-currant jelly) and a palpable after normal barium enema x-ray. She experienced
tender abdominal mass (2). It is a relatively rare temporal relief and was discharged. A week later,
entity in adults accounting for 5% of all she returned to our unit with the above
intussusceptions, and is said to cause 1-5% of all presentation.
intestinal obstructions in adults (3,4). On examination, she was ill-looking,
Intussusception is even all the more rare in the hypotensive (BP=89/60mmHg) and tachycardic
post-operative period. We herein report two cases (HR=112b/min) with a temperature of 37.9°c. The
of adult intussusception in the post-operative lungs were clinically clear. The abdomen was
period at a rural district hospital. distended centrally with visible peristalsis (Fig 1),
and she did not move with respiration. There was
CASE 1
1
University of Buea, Faculty of Health Sciences and Tubah District Hospital, Cameroon
2
University of Buea, Faculty of Health Sciences and Tubah District Hospital, Cameroon
3
Global Health Systems Solutions, Limbe, Cameroon
4
Tubah District Hospital, North West Region, Cameroon
Corresponding Author: Aminde L.N, Email: [email protected]
182 Ethiop J Health Sci. Vol. 25, No. 2 April 2015

diffuse tenderness with guarding and rebound

(percussion) tenderness. Hernia orifices were
normal. Bowel sounds were hyperactive. A
presumptive diagnosis of strangulated small bowel
obstruction was made. Plain abdominal and erect
chest x-rays were also normal. A complete blood
count was normal and HIV test was negative. The
patient was prepared and resuscitated for four
hours. Then, with satisfactory urine output, she
had emergency laparotomy.

Fig 2: Ileo-ileal intussusception (intra-operative)

CASE 2

A 36 year old male farmer was admitted to the

Surgical Unit presenting with a 2 days’ sudden
onset history of colicky abdominal pain (initially
occurring every 15mins, and later increased in
frequency). This was associated with copious
vomiting, mild abdominal distension and
constipation. He consulted at local Health Centre
and received analgesia which did not remedy his
pain. Clinical deterioration thus prompted
Fig 1: Visible peristalsis pre-operatively consultation. In the past, he was admitted for
progressive weight loss and an appendicectomy 3
Intra-operatively, there were dilated loops of small months prior to consultation. There was no history
bowel right to the terminal ileum where there was of tuberculosis in the past.
an ileo-ileal intussusception (Fig. 2) measuring Physical examination revealed a moderately
about 7cm in length. There was no free peritoneal dehydrated patient, BP=100/60mmHg, tachycardia
fluid, and bowel was viable. The intussusception (PR=108b/min). His temperature was normal and
was reduced from the apex by gentle traction and lungs were clinically clear. The abdomen was
retrograde pressure. An area of ischaemia was centrally distended, with an everted umbilicus and
noted with a perforation measuring ~ 0.5cm. Due did not move with respiration. There was
to the urgent nature of the case, bowel viability generalised tenderness, but no rebound tenderness.
was ensured and a limited resection was done. An There were hyper-resonant percussion notes and
ileo-ileal end-to-end anastomosis was done. tinkling bowel sounds. Hernia orifices were free.
Histopathology results of the resected specimen A working diagnosis of small bowel obstruction
revealed inflammatory lesions with no features of due to adhesions was again made. Blood tests
malignancy. She had a good post-operative were not contributory and he tested negative for
recovery and discharged after 8 days. HIV. Erect chest x-ray unremarkable but plain
abdominal x-ray revealed multiple air-fluid levels
and pneumoperitoneum. He could afford neither
an ultra sound nor CT scan. He was resuscitated
and underwent emergency laparotomy following
satisfactory urine output. Intra-operatively,
distended bowel loops were seen with a huge mass
 Intussusception as a Cause of Bowel… Aminde L.N et al 183

at the hepatic flexure of colon. Gross examination suggested it almost always involves laparotomy
of the mass revealed a 15cm colo-colic and bowel resection. This occurs especially when
intussusception with a tumor measuring 2cm x bowel viability is doubtful, or in the presence of a
2cm x 1.5cm, dense adhesions and omentum stuck lead point or causal pathology for which
to posterior abdominal wall. Following resection, malignancy has been reported to be 33%-77%.
histopathology reports of the sample revealed This is partly due to the fact that it is usually very
moderately differentiated adenocarcinoma of the difficult to differentiate benign from malignant
colon involving full thickness of the muscularis causes in enteric intussusceptions non-operatively
propria, as well as serosa with extensive (7). Other relatively rare causes like lipoma (5)
permeation of the lymphatics (Duke’s C). The and even parasitic infestation have been
patient suffered constipation post-operatively and demonstrated by Yersinia enterocolitica (2). In our
was later discharged on day 10 post-op with no first case following Caesarean section, there was
further complaints but referred for oncologic no lead point identified, but it should be noted that
evaluation and further management. co-existent colonic adenocarcinoma (instead
diagnosed in our second case following
DISCUSSION Appendicectomy) has been reported as lead point
following caesarean section, probably initiated by
Barbette was the first to describe intussusception
bowel oedema or post-operative ileus (9).
in the literature in 1674 (5). Since its discovery,
Reduction by hydrostatic decompression could be
intussusception has always been described as a
helpful in colonic intussusceptions if the bowel is
disease of infancy and early childhood. In the
not completely obstructed, though many authors
paediatric population, its occurrence is usually
advise against hydrostatic reduction with barium
idiopathic ~ 80% as opposed to the adult
or air in adult patients (10) which is all the more
population where in about 90% of the cases, there
difficult to achieve in rural and resource limited
is usually a lead point or pathology (6,7).
African settings as were our cases. Clinicians in
Intussusception has been documented to account
resource limited settings are thus advised to have a
for 0.1% of adult hospital admissions and 5-16%
high index of suspicion for intussusception in
of all intussusceptions (8). Intussusceptions are
adults presenting with features suggestive of
divided into enteric, colonic, ileo-caecal or
intestinal obstruction. Due to its non-specific
ileocolic. Enteric intussusceptions are those
clinical presentation in adults and management
confined only to the small intestine while colonic
challenges, intussusception should invariably be
are those confined to the large intestine. Most
considered as differential diagnosis for bowel
patients present with subacute (24.4%) or chronic
obstruction even in the post operative period in a
(51.2%) symptoms of abdominal pain, nausea,
bid to reduce morbidity and mortality.
vomiting and constipation. Hence, the non-
Intussusception is a rare entity in adulthood.
specific presentation of intussusceptions appears
An ultrasound scan is helpful but computerised
to be the main reason why a preoperative
tomography (CT) scan remains the mainstay of
diagnosis is difficult(7). Studies have shown that
pre-operative diagnosis albeit in resource limited
Ultrasound Scan of the abdomen is a relatively
settings as was the case here, a pre-op diagnosis
cheap and affordable diagnostic tool (6) but the
was all the more difficult due to financial
gold standard of diagnosis is the computerised
constraints and non-availability of such diagnostic
tomography (CT) Scan (6,7). Colour Doppler is
tools. Although a rare entity in adults,
also helpful in determining the degree of vascular
intussusception should still be thought of as a
compromise in the involved bowel segments.
differential diagnosis to intestinal obstruction even
Endoscopy is also of great value for pre-operative
in the post-operative period.
diagnosis as the lead point in the second case
could have been identified. However, the limited
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