Intussusception Resulting From Uncontrolled Severe Opioid-Induced Constipation and/or Chronic Cocaine Use

Introduction: Intussusception is a rare condition where part of the bowel slides into an adjacent segment. This condition can result in obstruction or even ischemia or infarction. Often a lead point is identified which triggers telescoping of one bowel segment into the other; this can be a polyp, tumor, diverticulum, or other abnormality. We present a rare case of intussusception in an adult with no identifiable causes other than chronic consumption of opioids and cocaine. Case Description/Methods: A 56-year-old man with active polysubstance abuse including daily intranasal heroin and cocaine use was admitted with a week of abdominal pain and constipation. His last bowel movement was one week prior to admission, though he did report ongoing flatus without nausea or vomiting. The abdomen was diffusely mildly tender to palpation, without rebound. There was no history of recent colonoscopy. Past surgeries included exploratory laparotomy for a right abdomen stab wound and open appendectomy. Urine toxicology was positive for cocaine and opioids. Computed tomography showed colo-colonic intussusception in the ascending colon plus a large colonic stool burden (Fig. 1a/b). While a lead point was suspected, no mass or focal lesion was identified. Diagnostic laparoscopy was performed to exclude underlying malignancy, showing extensive omental adhesions to the colon along the midline and right lower quadrant. However, no obvious colonic intussusception or mass was seen. The procedure was terminated with a plan for a bowel prep before colonoscopy, which again showed no mass or other colonic abnormality (Fig. 1c). The patient was discharged the following day on an aggressive bowel regimen. Discussion: Intestinal intussusception in adults is rare. The incidence is around 2-3 cases per million per year. Up to 90% cases of colonic intussusception are due to a structural lesion, many associated with malignancy. Cocaine acts as an indirect agonist of the sympathetic nervous system by binding to the dopamine transporter. Long-term use of cocaine reduces blood flow in the gastrointestinal tract, which can lead to decreased peristalsis and ischemia. Opioids also can inhibit intestinal peristalsis by acting on peripheral mu-opioid receptors in the smooth muscle. As no focal cause of intussusception was identified, reduced colonic peristalsis and even focal ischemia must be considered as possible etiologies in this patient and in similar cases where no lead point lesion is seen.Figure 1.: A, B: Abdominal computed tomography showing telescoping of the proximal ascending colon (yellow arrow) into the distal ascending colon (blue arrow) in axial (A) and coronal (B) images. C: An image of ascending colon during colonoscopy without finding of intussusception or focal mucosal abnormality.