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Case Report

Pediatric Emergencies Presenting in Pregnancy: A Report of Adult Intussusception

Michael Yuzefovich, MD; Jaclyn Lewis Albin; Charles J. Macri, MD

A 30-year-old woman, gravid 5, para 2, presented to the emergency department 10 days after an uncomplicated vaginal delivery. Her symptoms began 3 days postpartum and progressively worsened. Upon examination, she complained of diffused nonspecific abdominal pain (rated 7 out of 10) associated with low-level nausea and non-bloody diarrhea. She was otherwise healthy, with an unremarkable antepartum and labor course. She was afebrile upon examination. Her abdomen was soft with normoactive bowel sounds, though moderately tender at the lower mid quadrant. She was negative for rebound tenderness or guarding. Her pelvic examination and laboratory tests were noncontributory. A transvaginal ultrasound was negative. Based on a urine analysis, a urinary tract infection was diagnosed. The patient was sent home with trimethoprim/sulfamethoxazole and told to follow up in several days.

Over the next 2 days, her symptoms worsened. Fever and chills developed and she sought consultation with her ObGyn. Her abdomen revealed marked distention and rebound tenderness in all quadrants. An acute appendicitis was considered, and the patient was sent to the emergency department for further evaluation and surgical consultation.

Computed tomography (CT) imaging demonstrated a dilated loop of bowel with the transition point at the level of the cecum, suggesting a co-lonic bowel obstruction. Exploratory laparotomy revealed intussusception of the terminal ileum into the right colon. The surgeon resected the affected bowel segment and performed a primary anastomosis without difficulty. The patient had an uncomplicated postoper-ative course and complete recovery. The intussusception was secondary to an appendiceal tumor. Final pathology determined a benign mucinous cystadenoma.

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DISCUSSION

Intussusception is a condition in which one portion of bowel telescopes into an adjacent segment of bowel. This inevitably creates an obstruction and leads to one or both segments of bowel compromising their blood supply. Intussusception is primarily a pediatric disease, with fewer than 5% of cases occurring in adults.1,2 Pregnant patients, however, appear to represent a large portion of adult cases. The gravid patient is particularly vulnerable antepartum because of the ascension of the uterus into the abdominal cavity during the early second trimester. The gravid patient is also vulnerable postpartum, when the uterus involutes. Rapid change in uterine size affects the physiologic, and sometimes pathological, adhesions surrounding the bowel, causing a push- and-pull effect among adjacent bowel segments until one segment prolapses into another.

Bowel adhesions, however, explain only part of the picture. In adults (pregnant patients included), a lead point—the general term for a focal bowel lesion—causes 90% of adult cases.1-3 As a segment of distal bowel peristalsis, it pulls the lead point lesion and its attached bowel wall into it, creating the intussusception. The vast majority of these lead points result from a benign or malignant neoplasm. The reality is that approximately 45% of all tumor-related lead points are malignant.1,4 Thus, it is not the intussusception alone that accounts for the morbidity in these cases, but also the concomitant pathology associated with the lead point.

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DIAGNOSIS AND MANAGEMENT

The gold standard for diagnosing an intussusception is CT scan.1-3,5,7 CT is the most sensitive diagnostic modality, and also provides additional information about the anatomical location of the problem and any surrounding pathology that may be present.5,8 The classic signs on CT include a “pseudo kidney” in the longitudinal view and the “donut” and “target” signs in the transverse view.8 A CT scan should be considered even in the gravid patient, as combined abdominal and pelvic scanning emits radiation that is below the well-established threshold for fetal risk.

Appropriate management of adult cases is surgery, which should not be delayed.1-3,5,7 Although the optimal surgical technique remains debatable, most surgeons recommend a segmental resection, given the high incidence of malignancy.

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CONCLUSION

Clinicians should have a high clinical suspicion for intussusception in adult patients presenting with non-specific GI complaints. Pregnant patients are especially vulnerable, and judicious use of CT scanning may be necessary. Prompt surgical intervention is the standard of care, even in the gravid patient.

The authors report no actual or potential conflicts of interest in relation to this article.

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Michael Yuzefovich, MD, is Director of Gynecology, Mt. Vernon Hospital, and Assistant Professor; Jaclyn Lewis Albin, is a medical student; and Charles J. Macri, MD, is Director, Division of Maternal-Fetal Medicine. All are in the Department of Obstetrics and Gynecology, George Washington University School of Health and Health Sciences, Washington, DC.

References

1. Azar T, Berger DL. Adult intussusception. Ann Surg. 1997;226(2):134–138.
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3. Erkan N, Haciyanli M, Yildirim M, Sayhan H, Vardar E, Polat AF. Intussusceptions in adults: an unusual and challenging condition for surgeons. Int J Colorectal Dis. 2005;20(5):452–456.
4. Yalamarthi S, Smith RC. Adult intussusception: case reports and a review of literature. Postgrad Med J. 2005; 81(953):174–177.
5. Rea JD, Lockhart ME, Yarbrough DE, Leeth RR, Bledsoe SE, Clements RH. Approach to management of intussusception in adults: a new paradigm in the computed tomography era. Am Surg. 2007;73(11):1098–1105.
6. Chang CC, Chen YY, Chen YF, Lin CN, Yen HH, Lou HY. Adult intussusceptions in Asians: clinical presentations, diagnosis, and treatment. J Gastroenterol Hepatol. 2007; 22(11):1767–1771.
7. Palanivelu C, Rangarajan M, Senthilkumar, R, Madankumar MV. Minimal access surgery for adult intussusception with subacute intestinal obstruction: a single center’s decade-long experience. Surg Laparosc Endosc Percutan Tech. 2007;17(6):487–491.
   
8. Takeuchi K, Tsuzuki Y, Ando T, et al. The diagnosis and treatment of adult intussusception. J Clin Gastroenterol. 2003;36(1):18–21.

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