Letter to the Editor
Primary colo-colic intussusception as cause of intestinal obstruction
Intususcepción colo-cólica primaria como causa de oclusión intestinal
David Ambrona-Zafra, Juan José Segura-Sampedro
, Myriam Fernández Isart
Corresponding author
Departamento de Cirugía, Hospital Universitario Son Espases, Palma de Mallorca, Spain
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It is a disease that often affects the small intestine, mainly in the paediatric population. Adult intussusception is responsible for 1–5% of all intestinal obstructions.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> The percentage of colon intussusceptions over the total reaches 66%.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 69-year-old man with a history of hypertension, type 2 diabetes mellitus, revascularized ischaemic heart disease, stage <span class="elsevierStyleSmallCaps">IV</span> chronic kidney disease, morbid obesity, intestinal angina secondary to superior mesenteric artery stenosis with endovascular <span class="elsevierStyleItalic">stent</span> and previous appendectomy, which is referred to our centre from the district hospital after finding in an abdominal computed tomography (CT) of abrupt calibre change in the ascending colon area with discrete wall thickening, compatible with mechanical obstruction.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient reported chronic constipation symptoms exacerbated in the last 2 weeks. For this reason, a diagnostic colonoscopy extending to the ileocecal valve was performed 6 months earlier, with no lesions being found. He presented with nausea and vomiting associated with severe pain and abdominal distension in the last 24<span class="elsevierStyleHsp" style=""></span>h. The blood count showed 13,300 leukocytes per microlitre, and vital signs within normal levels, except fever of 37.5<span class="elsevierStyleHsp" style=""></span>°C. Urgent surgery was indicated after confirming the previously discussed intestinal occlusion by abdominal CT, with cecum diameter up to 17<span class="elsevierStyleHsp" style=""></span>cm, incompetent ileocecal valve and dilatation of the terminal ileum.</p><p id="par0020" class="elsevierStylePara elsevierViewall">An urgent laparotomy was decided, observing a clear round calibre change in the ascending colon, without signs of neoplasm or compatible lesion. Given that the cecum was ischaemic and with signs of suffering, right hemicolectomy was performed with mechanical isoperistaltic ileocolic anastomosis.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The postoperative period was complication-free. Given the high comorbidity, the patient was admitted to the anaesthetic resuscitation unit for 48<span class="elsevierStyleHsp" style=""></span>h, being discharged 8° days after surgery.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The anatomopathological study showed a dilated cecum with congestive serosa, showing violaceous areas and some fibrin deposits. A circumferential area with serosa retraction was observed at 7<span class="elsevierStyleHsp" style=""></span>cm from the distal resection margin, which, at the opening of the specimen coincided with a mucosal fold similar to a prolapse. It was accompanied by foci of thinned mucosa and ulcerated areas of ischaemic appearance, said area occupying 15<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>3.5<span class="elsevierStyleHsp" style=""></span>cm of diameter in the circumference, producing ischaemic necrosis of the cecum secondary to colonic intussusception.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Adult intestinal intussusception is usually secondary to both benign and malignant lesions that cause intussusception. Cases of lipomas, polyps, adenocarcinomas<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> and even appendicular processes<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> have been described.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The most common locations in the digestive tract are transition areas between the free-moving segments and those fixed to the retroperitoneal space or due to adhesions.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Depending on the site, they are divided into: enteroenteric, including only small intestine, colocolic, when it is exclusively segments of large intestine, ileocolic, defined as prolapse of the terminal ileum inside the ascending colon, distinguishing it from the ileocecal variant, where the ileocecal valve is the starting point of intussusception.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Primary spontaneous colocolic intussusception is extremely rare. The only cases described are associated with colonoscopy.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Preoperative diagnosis is usually suspected in CT when one colon segment is inside another segment or a small intestine segment is found within the colon over a length of at least 10<span class="elsevierStyleHsp" style=""></span>mm, including fat and mesenteric vessels in the intussusception lumen, or an obvious intestinal intussusception is observed under a longitudinal perspective.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Ultrasound diagnosis is not recommended in situations of intestinal occlusion because it increases the risk of perforation.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Surgical treatment is of choice in case of intestinal occlusion, either by laparoscopic approach or by laparotomy, with the removal of the affected segment being necessary in most cases. The established diagnosis is made macroscopically after intussusception is confirmed and after a pathology study for the underlying cause has been carried out.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ambrona-Zafra D, Segura-Sampedro JJ, Fernández Isart M. Intususcepción colo-cólica primaria como causa de oclusión intestinal. Med Clin (Barc). 2018;151:41–42.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intussusception of the bowel in adults: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. 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Gollub" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Am J Roentgenol" "fecha" => "2011" "volumen" => "196" "paginaInicial" => "W580" "paginaFinal" => "W585" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack359057" "titulo" => "Acknowledgements" "texto" => "<p id="par0060" class="elsevierStylePara elsevierViewall">Natalia Pujol, Magarita Gamundi and Francesc Xavier González-Argenté who also contributed to the management and decision-making of the case.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015100000001/v1_201807170422/S2387020618301992/v1_201807170422/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015100000001/v1_201807170422/S2387020618301992/v1_201807170422/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020618301992?idApp=UINPBA00004N" ]
