A Case of Synchronic, Self-Resolved, Idiopathic Adult Intussusception: 3068

Introduction Adult intussusception constitute less than 5 percent of intussusception cases. While in children management is conservative, in adults almost always require surgical intervention. We report a case of multiple, self-limiting small intestine intussusceptions in a young adult female without a causative factor. Case Description A 26 year old female with past medical history of peptic ulcer disease, treated with pantoprazole 40mg daily, presented with sudden onset severe left lower quadrant pain that woke her from sleep. It was intermittent, associated with vomiting and diarrhea. No rectal bleeding, fever, sick contacts or recent travel. Vital signs: BP 152/65 mmHg, HR 95 bpm, RR 18 rpm, O2 saturation 100% at room air and a temperature 98°F. Physical exam was pertinent for normoactive bowel sounds, left upper quadrant tenderness with no rebound or guarding and no distension. CBC, CMP and Lipase were unremarkable. Abdominal X-ray (Fig A) showed areas of air-fluid levels in the small intestine. CT-scan of the abdomen (Fig B) revealed several foci of small to small bowel intussusceptions without evidence of obstruction or any intraabdominal pathology. She underwent exploratory laparoscopy, no areas of ischemia or abnormalities were identified. Her symptoms resolved and abdominal x-rays post-operatively confirmed resolution (Fig C). Further work-up included colonoscopy and upper endoscopy, capsule endoscopy, CT Enterography, and a Meckel's scan which failed to reveal any pathology. Patient has not had a recurrence. Discussion Intussusception is a rare entity in adults. Proposed theories include protruding lesions in the bowel wall or irritants within the lumen that alter normal peristaltic activity, thereby initiating invagination. The classical pediatric triad of abdominal pain, palpable mass and hematochezia is only present in one third of the adult cases. The classical sign on CT-scan is sausage-shaped soft tissue mass with an eccentric area of mesenteric fat contained within. Treatment is surgical in adults given the high incidence of bowel gangrene and prognosis is determined by the underlying factor. In this case, no area of ischemia or abnormalities were found during exploratory laparotomy and further out-patient work-up did not reveal any causative underlying pathology. Self-resolving cases are seen in the pediatric population or in adults with underlying small intestine pathology. Hence, our case represents an uncommon clinical outcome.3068_A Figure 1. Abdominal X-ray demonstrated scattered air-fluid levels are seen suggesting a possible mild ileus3068_B Figure 2. Image from CT Abdomen with contrast Axial plane slide 43 demonstrated one of the multiple foci of proximal small bowel to small bowel intussusceptions.3068_C Figure 3. Abdominal X-ray demonstrated no evidence of bowel obstruction.