Adult ileo-ileal Intussusception secondary to an Inflammatory fibroid polyp a case report

Abdelkafi Mohamed Taha | Trigui Racem | Sellami Mohamed | Fodha Mahmoud | Helali Kamel |

La tunisie chirurgicale - 2022 ; Vol 2022

Resumé

Unlike children, Intussusception is a rare condition in the adult population, it is often associated withorganic lesion serving as a lead point.

We report an unusual case of a 37 years old male admitted for ileo-ileal intussusception due to an inflammatory fibroid polyp. CT Scan revealed a jejunal thickening resulting in an ileo ileal invagination with a cockade image.

Ileal resection with side-to-side anastomosis was performed with histology confirming the diagnosis.

ileo-ileal intussusception is a rare but serious condition in adults. Excellent results could be anticipated with a well-timed diagnosis and surgical treatment.

Mots Clés

ileo-ileal Intussusception

Introduction :

Intussusception is defined as the telescoping of a bowel segment along with itsmesentery (invaginated loop), into an adjoining segment (invaginating or receptor loop) following peristalsis modifications.

Intussusception can be caused by several triggers depending on age: of instance, the main etiology for children tends to be idiopathic or viral, but in adults, 80 to 90 % of cases are organic: 65 % of which are due to neoplasms. Benign pathologies represents only 25 % of cases and 10 % are idiopathic [1], [2].

We present a case of ilea ileal intussusception secondary to an ileal Inflammatoryfibroid polyp.

 

Article

Presentation of Case

A 37 years old male, operated for appendicular peritonitis 14 years ago, admitted for left side abdominal pain evolving for 20 days. He also complained of vomiting, but with no constipation or abdominal distension.

Physical examination showed a localized tenderness in the left hypochondrium, but no rigidity or rebound tenderness. There was no significant abdominal distension or tympanist at percussion.

Laboratory investigations were within normal limits.

Abdominal X-ray showed air-fluid levels suggesting bowel obstruction, there for a CT scan was done showing:A jejunal wall thickening of 18 mm, extended over 9 cm with intestinal invagination image giving a cockade image.But no free air or fluid in the abdomen. (Fig 1CT)

The patient was kept forty-eight hours under observation in the hospital with n.p.o, nasogastric tube under suction,and on IV fluids.

At the end of the observation period, a follow-up abdominal CT scan does not show resolution of the intussusceptions, there for the patientunderwent an emergency laparotomy.

During the operation: the diagnostic of jejunal intussusception was confirmed: at approximately 150 cm of Treize angle, there was a 15 cm of jejunal bowel telescoped into the adjoining segment, and at the center,a luminal irregular mass 4 cm in diameter was found, but with no signs of bowel suffering. Ileal resection with side-to-side anastomosis was performed. There were no significant postoperative complications.(Fig 2)

Anatomopathological findings concluded with an ileal Inflammatoryfibroid polyp.(Fig 3)

Discussion

Intussusception is defined as a prolapse of the bowel with its mesenteric fold inside the lumen of the adjacent segment as a consequence of compromised peristalsis. This phenomenon causes obstruction, blocking mesenteric vascular flow leading to ischemia[3].

In the adult population intussusception’s most common site is the small bowel[1].

As opposed to children’s intussusception which is 90% idiopathic, when it occurs in adults an anatomical lesion is reported in 90% of the cases [4], [5]and in most cases (two-thirds of cases),benign tumors of the small bowel are diagnosed [5].

Unlike children, reported signs with adults are mainly subacute and rarely presented as an acute abdomen [5].

Intussusception presentation varies considerably and the majority of adults showed nonspecific and intermittent abdominal pain, nausea, vomiting[1], [6].

Due to the vague and varied number of symptoms, pre-operative diagnosis is difficult there for imaging modalities are necessary.

In matters of Intussusception, abdominal CT is considered to be the most useful imaging modality showing: the site, level, etiology, and possible complications [5].

Inflammatory fibroid polyp (IFP)isa rare tumor-like lesion that can develop anywhere in the gastrointestinal tract, mostly localized in the gastric antrum, followed by the small intestine as the second site of origin.

Histologically speaking, IFP is formed of mononuclear spindle-shaped cells associated with inflammatory infiltration  [12]

IFPs can imitate many other benign and malignant tumors, and differentiation can be difficult mainly with gastrointestinal stromal tumors, highlighting the role of immunohistochemical studies [9]

Immunohistochemical studies show positivity of CD34, implying that these pseudotumor lesions may develop from primitive blood cells [10]Negative PS100 and CD117 staining differentiates an IFP from gastrointestinal stromal tumors and neurogenic tumors [8]

 

Conclusion

Preoperative diagnosis of intussusception in the adult population can be difficult due to its various clinical presentations. Computed tomography is a cornerstone in a positive diagnosis. Any Delay in management can be associated with complications.

Surgery is still the main course of action, and anatomopathological findings dictate postoperative management.

Références

 

[1]          A. El-Sergany, A. Darwish, P. Mehta, et A. Mahmoud, « Community teaching hospital surgical experience with adult intussusception: Study of nine cases and literature review », Int. J. Surg. Case Rep., vol. 12, p. 26‑30, 2015, doi: 10.1016/j.ijscr.2015.03.032.

[2]          M. Darouichi, « Triple invagination intestinaleaiguërévélant un syndrome de PeutzJeghers », Feuill. Radiol., vol. 51, no 4, p. 216‑221, sept. 2011, doi: 10.1016/j.frad.2011.06.002.

[3]          A. Zubaidi, F. Al-Saif, et R. Silverman, « Adult intussusception: a retrospective review », Dis. Colon Rectum, vol. 49, no 10, p. 1546‑1551, oct. 2006, doi: 10.1007/s10350-006-0664-5.

[4]          S. Singhal et al., « Adult Ileo-Ileo-Caecal Intussusception: Case Report and Literature Review », Case Rep. Surg., vol. 2012, p. e789378, déc. 2012, doi: 10.1155/2012/789378.

[5]          H. A. Abdulla, T. H. A. Taei, B. Alsayed, et K. Alawadhi, « Ileo-caecal intussusception secondary to lipoma in an adult: A rare cause for intestinal obstruction », Radiol. Case Rep., vol. 15, no 9, p. 1693‑1696, sept. 2020, doi: 10.1016/j.radcr.2020.07.008.

[6]          D. E. Lee et J. Y. Choe, « Ileocolic intussusception caused by a lipoma in an adult », World J. Clin. Cases, vol. 5, no 6, p. 254‑257, juin 2017, doi: 10.12998/wjcc.v5.i6.254.

[7]          T. M. Jacobs et A. L. Lambrianides, « Inflammatory fibroid polyp presenting as intussusception », J. Surg. Case Rep., vol. 2013, no 2, p. rjt005, févr. 2013, doi: 10.1093/jscr/rjt005.

[8]          A. P. Wysocki, G. Taylor, et J. A. Windsor, « Inflammatory fibroid polyps of the duodenum: a review of the literature », Dig. Surg., vol. 24, no 3, p. 162‑168, 2007, doi: 10.1159/000102099.

[9]          S. Akbulut, « Intussusception due to inflammatory fibroid polyp: A case report and comprehensive literature review », World J. Gastroenterol. WJG, vol. 18, no 40, p. 5745‑5752, oct. 2012, doi: 10.3748/wjg.v18.i40.5745.

[10]        R. Nonose, J. S. Valenciano, C. M. G. da Silva, C. A. F. de Souza, et C. A. R. Martinez, « Ileal Intussusception Caused by Vanek’s Tumor: A Case Report », Case Rep. Gastroenterol., vol. 5, no 1, p. 110‑116, mars 2011, doi: 10.1159/000326930.

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

     Figure 1: ileo-ileal Intussusception aspect on CT Scan

 

                                                                            

 

Figure 2 : ileo-ileal Intussusception


 

 

 

                Figure 3 : Inflammatory fibroid polyp