Discussion:
Intussusception happens when the proximal segment of the bowl telescope into the adjacent loop, causing obstruction and affecting the blood supply, which could lead to intestinal obstruction, ischemia, perforation and sepsis. Intussusception has a variety of types according to the involved segments. [6]
It is more common to be a pediatric presentation than in adults, found in less than 1 in 1300 abdominal operations. [7]
In adults, its aetiology is always related to neoplasm as a lead point in nearly 90% of cases. Approximately 60 to 80% of intussusceptions in the large bowel are caused by malignant tumors. [3] So if it is predicted by imagining, the suspicion of tumours is the top priority, as in our case.
Other risk factors that lead to an intussusception may include:
In a previous study the lesions were found to be varied from 3.5 cm to 8.5 cm in diameter. [9] Inflammatory diseases of colon or appendix can also play a leading point for intussusception.
Symptoms are sometimes vague, including colicky abdominal pain, which can be intermittent or constant, vomiting (can be bilious), bloating, and bloody stool. [10]
Inpatient presented with non-emergency nonspecific abdominal pain CT scan appears to be the most sensitive diagnostic tool for picking intussusception with a diagnostic accuracy of 58%–100% and a specificity of 57–71%. [11]
The CT findings one can illustrate will be a mass-like lesion, including the inner intussusceptum, an eccentric fat density mass that represents the intussuscepted mesenteric fat, and the outer intussuscipiens, and this appears as a “target” or a “sausage” mass according to imaging plane.
Additionally, a CT scan can aid in identifying the pathological lead points, and its extension also could help in anticipating the vascular status of the bowel. In some circumstances, a CT scan can predict the possibility of self-resolution of the condition. [6]
In our case, the abdominal CT scan picks up the colo-colic intussusception and the colonic mass extension that sharply changes the forward workup of the patient.
Ultrasound is also a helpful tool but less sensitive than CT scans. The characteristic features that could be revealed by ultrasound include target and doughnut signs in transverse view and pseudo-kidney signs in longitudinal view. [12]
The ultra-sonographic findings at the first presentation of our patient raised the colonic mass suspension, so an immediate CT scan was ordered. However, it did not elicit the presence of intussusception.
Surgical interventions are the mainstay of management of adult intussusception as it carries a very high incidence of underlying malignancy. After supportive emergency management, preoperative preparation of the patient for resection according to the appropriate oncological assessment is the plan. [12]
Intraoperatively, the location, size, and cause of the intussusception and the viability of the bowel determine the appropriate decision for the surgical procedure. [13]
As the management is purely surgical in adults, there is still controversy about the trail of reduction intraoperatively before resection. There is a debate between two opposing schools. One supports intraoperative reduction as it may minimise unnecessary bowel resection. Another school is fighting intussusception reduction as the risk of dissemination of the malignant cells during the procedure. [14]
Adult intussusception carries a poor prognostic picture due to the delay in diagnosis of its nonspecific presentation and the prevalence of underlying malignancy. This return the complications of vascular supply to be jeopardised and sepsis to manifest earlier with a high mortality rate, especially in developing settings such as Sudan. [12]