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:
- Mass (benign or malignant)
- Anatomical changes
- Post-surgical adhesions
- Endometriosis
- Idiopathic
- Fibroids
- Gastrostomy tube
- Jejunostomy tube. [8]
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]