Intussusception in the Geriatric Population: A Case Report

Abstract

Recurrent abdominal pain in the adult population is a complex symptom with a broad spectrum of diagnoses. The diagnosis of intussusception in the elderly is considerably rarer than in the younger population. High clinical suspicion is required, and imaging is needed for confirmation. Here, we present and discuss the clinical course and management of an 82-year-old female who underwent small bowel resection following recurrent intussusception that was confirmed by imaging and at the time of surgery. The patient was known for having a history of polyps, and the pathology report described a large tubulovillous adenoma found on the resected small bowel specimen. The patient was discharged after surgery with complete remission. This case report intends to explore the importance of surgical intervention versus conservative management in a patient with a similar clinic presentation. This report also intends to highlight the importance of surgical intervention to prevent intussusception-related complications and reduce patient mortality further.

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Published 05/02/2022
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Intussusception in the Geriatric Population: A
Case Report
Benoit Boucher , Orlando Fleites , Rio Varghese , Julius Myuran Nagaratnam , Fabrice Yabit , Juaquito
Jorge
1. Surgery, Saint James School of Medicine, Chicago, USA 2. Surgery, Saint James School of Medicine, Park Ridge, USA
3. Surgery, Saint James School of Medicine, West Virginia, USA 4. Surgery, Avalon University School of Medicine,
Chicago, USA 5. General and Bariatric Surgery, West Suburban Hospital, Oak Park, USA
Corresponding author: Benoit Boucher, bboucher@mail.sjsm.org
Abstract
Recurrent abdominal pain in the adult population is a complex symptom with a broad spectrum of
diagnoses. The diagnosis of intussusception in the elderly is considerably rarer than in the younger
population. High clinical suspicion is required, and imaging is needed for confirmation. Here, we present
and discuss the clinical course and management of an 82-year-old female who underwent small bowel
resection following recurrent intussusception that was confirmed by imaging and at the time of surgery. The
patient was known for having a history of polyps, and the pathology report described a large tubulovillous
adenoma found on the resected small bowel specimen. The patient was discharged after surgery with
complete remission. This case report intends to explore the importance of surgical intervention versus
conservative management in a patient with a similar clinic presentation. This report also intends to
highlight the importance of surgical intervention to prevent intussusception-related complications and
reduce patient mortality further.
Categories: Internal Medicine, Gastroenterology, General Surgery
Keywords: geriatric population, transition point, adenoma, exploratory laparotomy, small bowel obstruction,
intussusception
Introduction
Intussusception is the invagination of a proximal portion of the intestine into its distal aspect [1], often
referred to as telescoping [2]. The condition is typical among pediatrics and infants, with a peak incidence
occurring in infants of 5-7 months of age with an incidence of 74 per 100,000 [3,4] in children under one
year old. Typical clinical presentations include colicky abdominal pain, mucus or blood-tinged stool, emesis,
diarrhea [5,6], and a palpable mass on the abdomen during physical examination [6]. Small bowel
intussusception is more expected in the pediatric population and is rare among adults, accounting for less
than 5% of all cases [7].
The causes of intussusception in adults are diverse. Many etiologies such as neoplasms, enteric autoimmune
pathologies, history of intra-abdominal surgeries, and gynecologic conditions such as endometriosis are
known to cause intussusception [7]. The common complications associated with this condition include small
bowel obstruction (SBO), bowel ischemia, necrosis, bowel perforation with peritonitis, and sepsis [8], as a
result requiring urgent care [1,9].
Management for adult patients with presenting signs and symptoms suggestive of intussusception or other
obstructive bowel pathologies often involves detection via an abdominal computed tomography (CT) scan
[10,11], which is often the gold standard for early detection [7,11]. In contrast to the pediatric population,
where endoscopy is diagnostic and usually therapeutic, intussusceptions are beyond the reach of endoscopes
in their geriatric counterparts. The preferred surgical intervention is an exploratory laparotomy with bowel
resection and anastomosis or laparoscopic bowel resection with bowel anastomosis [12]. Surgical
intervention is required due to possible bowel obstruction, ischemia, or necrosis [13].
Case Presentation
An 82-year-old female presented to the emergency room complaining of cloudy, odorous urine, weak
stream, and generalized weakness for two days. She also reported constipation for approximately one month
and poorly tolerating oral intake due to nausea and vomiting. She denied abdominal pain, hematochezia,
melena, excessive belching, bloating, diarrhea, hematuria, and dysuria.
The patient's past medical history is significant for recurrent UTI, well-controlled DM2, atrial fibrillation,
multiple CVA with left-sided residual impaired mobility of lower and upper extremities, and hypertension.
Surgical history is notable for hysterectomy, oophorectomy, appendectomy, and hernia repair. The patient
denied illicit drug use, along with the usage of alcohol. Medication regimen include atorvastatin, Eliquis,
1 2 3 4 1
5
Open Access Case
Report DOI: 10.7759/cureus.24663
How to cite this article
Boucher B, Fleites O, Varghese R, et al. (May 02, 2022) Intussusception in the Geriatric Population: A Case Report. Cureus 14(5): e24663. DOI
10.7759/cureus.24663

amiodarone, enalapril, hydrochlorothiazide, insulin glargine, senna, bisacodyl, pantoprazole, labetalol,
metoprolol, and warfarin. Allergies were notable for codeine, penicillin, quinine, and contrast media.
CT scan revealed that a long jejunal segment was intussuscepted, with stool impaction in the colon.
Although the patient denied a family history of gastrointestinal malignancy, concerns were raised upon the
patient mentioning that polyps were found 10 years ago on prior colonoscopy. The patient could not recall
what type or where were those polyps located. The patient asked for conservative management, but an air
enema was not a viable option and is contraindicated for this patient, given the proximal nature of the
intussusception and age. The gastroenterology specialist started the patient on saline enemas, and the
patient was educated on how to use saline enemas for fecal evacuation regularly once discharged. The
patient was ultimately discharged upon imaging, indicating improvement of both stool impaction and
intussusception since starting the saline enemas.
The patient presented to the emergency department five months later complaining of vomiting, nausea, lack
of solid feces with enemas, and purulent urination that started three days before her visit. Laboratory results
revealed elevated liver enzymes and leukocytosis, and urinalysis was positive for nitrites, leukocytosis, red
blood cells, and bacteria. The patient denied any recent diet changes or travels and consistently used her
enemas but noted that her stools are now watery. The patient refused surgical evaluation and was discharged
on Bactrim to treat acute cystitis and Zofran to control nausea and vomiting.
The patient returned to the emergency room in acute distress three months later, complaining of
generalized abdominal pain, constipation, nausea, and vomiting for a month with a physical examination
revealing mild abdominal distension and disclosed still being compliant with her enemas. Laboratory results
were normal. CT with IV contrast (Figure 1) revealed small bowel obstruction secondary to intussusception
in the right abdomen distal to the dilated bowel loops (up to 4.6 cm in distension), anasarca, distended
urinary bladder, and pericholecystic fluid with mild wall thickening and a 3.3 cm cyst in the liver. The
patient agreed to surgical intervention and was scheduled for an exploratory laparotomy. The risks and
benefits of the procedure were discussed with the patient, and consent was obtained.
FIGURE 1: CT with intravenous contrast of the abdomen showing the
transition point
Red arrow: transition point
Exploratory laparotomy was performed under general anesthesia with small bowel resection and primary
anastomosis. Dilation of the stomach via insufflation was performed, the proximal small bowel was noted,
the small bowel was eviscerated, and the transition point (Figure 2) was exposed. The telescoped portions of
the bowel were resected, and anastomosis was created. The resected specimen was sent to pathology for
further analysis, and the rest of the small bowel running from the ligament of Treitz down to the ileocecal
valve was examined and showed no abnormalities. No adhesion, signs of bowel perforation or ischemia, or
2022 Boucher et al. Cureus 14(5): e24663. DOI 10.7759/cureus.24663 2 of 5

any other complications were noted intraoperatively, and the patient was maintained on a small bowel rest
regimen, DVT prophylaxis, and antibiotics for 24 hours postoperatively. Bowel functions started
convalescing on postoperative day 2. The pathology report returned positive for tubulovillous adenoma in
the jejunum measuring 6 × 5.3 × 2.2 cm without evidence of cancer and negative dysplasia in all 12 regional
lymph nodes analyzed. The margins of the specimen were free of dysplasia. Upon normal serial abdominal X-
ray and return of bowel functions, the patient was discharged.
FIGURE 2: Small bowel transition point
Discussion
Intussusception is the overlapping of a proximal segment of the bowel into the lumen of its distal segment
[14]. Adult intussusception cases typically have a malignant etiology, from which the abnormal growth
serves as the lead point. At the transition point, peristaltic contractions constrict and relax the lumen,
allowing for the invagination of the proximal segment into the distal bowel [2]. Adult intussusceptions
account for less than 5% of all cases [7], from which 52% localize in the small bowel [15]. Intussusception
caused by detectable structural lesions such as adhesions, inflammatory bowel diseases, Meckel's
diverticulum, or neoplasm is called secondary intussusception [13]. The classic presentation of
intussusception involves abdominal pain, currant jelly stools, and palpable tender mass, which is not
generally seen in adult intussusception. Repeated bouts of nonspecific intermittent abdominal pain are a
common complaint in adult patients diagnosed with intussusception [16].
2022 Boucher et al. Cureus 14(5): e24663. DOI 10.7759/cureus.24663 3 of 5

The cause of our patient's adult intussusception was a large tubulovillous adenoma, measuring 6 × 5.3 × 2.2
cm, with no evidence of malignancy. Tubulovillous adenomas have a combination of tubular and villous
makeup, with the latter alone having the more eminent propensity for malignancy [17]. Tubulovillous
adenomas are poorly differentiated tumors and benign. The early stages of the adenoma are asymptotic, but
unexpected growth can cause morbidity and ultimately become malignant. Treatment guidelines for
tubulovillous adenomas require an extensive bowel resection to prevent the neoplasm from developing into
adenocarcinoma. SBO due to a tubulovillous adenoma in the jejunum accounts for less than 2% [18], while
70% are secondary to adhesions from previous abdominal surgeries. Abdominal pain is considered the most
common symptom for a patient with SBO, generally due to either partial or complete obstruction. Partial
SBO will still have flatus and some stool traveling through the intestine. In contrast, complete SBO will have
bowel obstination with an empty rectum [19].
Abdominal computed tomography (CT) scan is the gold standard for diagnosing intussusception and SBO. It
is the most sensitive imaging of choice due to its ability to distinguish the absence or presence of a lead point
in intussusception. Radiographic images of a "target sign," "bull's eye," or "doughnut sign" are auxiliary in
diagnosing intussusception. A diagnostic CT scan for SBO will show dilated bowel loops with a transition
point [20]. CT scan can be a reliable indicator of intussusception and SBO, although determining the
underlying etiology can remain unclear through imaging.
Conclusions
Although rare in the geriatric community, small bowel intussusception in the majority of cases results from
a pathological lead point. Such was the case for our 82-year-old patient, who was found to have a sizeable
tubulovillous adenoma albeit devout of any malignancy. This case displayed the importance of advocating
surgical over conservative management since nine months of enemas did not initially solve the condition.
Air enema remained an unviable option throughout the course in adult and geriatric populations due to the
proximity of the intussusception that air could not reach. Exploratory laparotomy remains the
curative option of choice in any nonpediatric population and pathology to be at the frontline for possible
further treatment based on the etiology report of the lead point.
Additional Information
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In
compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services
info: All authors have declared that no financial support was received from any organization for the
submitted work. Financial relationships: All authors have declared that they have no financial
relationships at present or within the previous three years with any organizations that might have an
interest in the submitted work. Other relationships: All authors have declared that there are no other
relationships or activities that could appear to have influenced the submitted work.
References
1. Marsicovetere P, Ivatury SJ, White B, Holubar SD: Intestinal intussusception: etiology, diagnosis, and
treatment. Clin Colon Rectal Surg. 2017, 30:30-9. 10.1055/s-0036-1593429
2. Shaheen K, Eisa N, Alraiyes AH, Alraies MC, Merugu S: Telescoping intestine in an adult . Case Rep Med.
2013, 2013:292961. 10.1155/2013/292961
3. Esteghamati A, Joulani M, Sayyahfar S, Salahi S, Babaie M, Shamshiri AR, Fahimzad A: Incidence of
intussusception in children less than five years of age: a pre-rotavirus vaccine survey from Iran, 2010-2015.
Med J Islam Repub Iran. 2020, 34:40. 10.34171/mjiri.34.40
4. Jiang J, Jiang B, Parashar U, Nguyen T, Bines J, Patel MM: Childhood intussusception: a literature review .
PLoS One. 2013, 8:e68482. 10.1371/journal.pone.0068482
5. Mandeville K, Chien M, Willyerd FA, Mandell G, Hostetler MA, Bulloch B: Intussusception: clinical
presentations and imaging characteristics. Pediatr Emerg Care. 2012, 28:842-4.
10.1097/PEC.0b013e318267a75e
6. Thanh Xuan N, Huu Son N, Huu Thien H: Treatment outcome of acute intussusception in children under two
years of age: a prospective cohort study. Cureus. 2020, 12:e7729. 10.7759/cureus.7729
7. Panzera F, Di Venere B, Rizzi M, et al.: Bowel intussusception in adult: prevalence, diagnostic tools and
therapy. World J Methodol. 2021, 11:81-7. 10.5662/wjm.v11.i3.81
8. Chang CC, Chen YY, Chen YF, Lin CN, Yen HH, Lou HY: Adult intussusception in Asians: clinical
presentations, diagnosis, and treatment. J Gastroenterol Hepatol. 2007, 22:1767-71. 10.1111/j.1440-
1746.2007.04907.x
9. Lu T, Chng YM: Adult intussusception. Perm J. 2015, 19:79-81. 10.7812/TPP/14-125
10. Dadlani A, Lal S, Shahani B, Ali M: Ultrasonography for the diagnosis of intussusception in children: an
experience from Pakistan. Cureus. 2020, 12:e9656. 10.7759/cureus.9656
11. Kim YH, Blake MA, Harisinghani MG, Archer-Arroyo K, Hahn PF, Pitman MB, Mueller PR: Adult intestinal
intussusception: CT appearances and identification of a causative lead point. Radiographics. 2006, 26:733-
44. 10.1148/rg.263055100
12. Aydin N, Roth A, Misra S: Surgical versus conservative management of adult intussusception: case series
and review. Int J Surg Case Rep. 2016, 20:142-6. 10.1016/j.ijscr.2016.01.019
13. Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, Theodosopoulos T:
2022 Boucher et al. Cureus 14(5): e24663. DOI 10.7759/cureus.24663 4 of 5

Intussusception of the bowel in adults: a review . World J Gastroenterol. 2009, 15:407-11. 10.3748/wjg.15.407
14. Potts J, Al Samaraee A, El-Hakeem A: Small bowel intussusception in adults . Ann R Coll Surg Engl. 2014,
96:11-4. 10.1308/003588414X13824511650579
15. Hadid T, Elazzamy H, Kafri Z: Bowel intussusception in adults: think cancer! . Case Rep Gastroenterol. 2020,
14:27-33. 10.1159/000505511
16. Khanna V, Reddy T, Yesilyaprak KA, Eshman Y, Tegeltija V: Idiopathic transient small bowel
intussusception in an adult. Am J Gastroenterol. 2021, 116:S1258. 10.14309/01.ajg.0000785716.64654.ce
17. Wiseman S, Bugis S, MacFarlane J: Jejunal adenoma presenting with gastrointestinal bleeding . Can J Surg.
2007, 50:223-4.
18. Azimi-Ghomi O, Kahane G: Ileal tubulo-villous adenoma causing small bowel obstruction in a virgin
abdomen. Cureus. 2021, 13:e17421. 10.7759/cureus.17421
19. Pujahari AK: Decision making in bowel obstruction: a review . J Clin Diagn Res. 2016, 10:PE07-12.
10.7860/JCDR/2016/22170.8923
20. Li Z, Zhang L, Liu X, Yuan F, Song B: Diagnostic utility of CT for small bowel obstruction: systematic review
and meta-analysis. PLoS One. 2019, 14:e0226740. 10.1371/journal.pone.0226740
2022 Boucher et al. Cureus 14(5): e24663. DOI 10.7759/cureus.24663 5 of 5