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Spontaneous reduction of ileoileal adult intussusception after blunt abdominal injury
American Journal of Emergency Medicine xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Spontaneous reduction of ileoileal adult intussusception after blunt abdominal injury Abstract This is the first case report of an adult who had spontaneous reduction of ileoileal intussusception occurred after punching to the abdomen. A 40-year-old man was brought to our emergency department by ground ambulance due to pounding and punching a few hours ago. Physical examination showed multiple dermabrasions on his face, abdomen, and lower extremities. All other examinations were unremarkable except that of mild abdominal pain. Laboratory results gave no clues. On abdominal x-ray, paucity of intestinal gas, pseudomass and surrounding gas appearances were visible. No nausea or vomiting occurred during observation. His abdominal pain resolved gradually. On the 24th hour after admission, control computed tomography showed that the findings of intussusception disappeared. He was discharged after 1 day of observation. Outpatient follow-up did not show any abnormality. We suggest that, in patients with mild to moderate trauma, even if the patient has mild abdominal pain, physicians should rule out invagination. Computed tomography is the suggested imaging modality. These patients should be kept in close follow-up. If symptoms resolve and intussusception findings disappear in computed tomography, no further treatment is required. Intussusception is common in early childhood. Intussusception due to blunt injury is rare and not predominant in the pediatric population. There are only a few adult cases [1]. Here, we present a 40-year-old man who was exposed to blunt abdominal trauma. He had moderate abdominal pain and computed tomography (CT) showed a “target” lesion that was specific for invagination. Abdominal CT revealed target sign in the axial view, and coronal views demonstrated pseudokidney or the sandwich sign. A 40-year-old man was brought to our emergency department by ground ambulance due to pounding and punching a few hours ago. He had no chronic illness and no drug or substance abuse. His vital signs were within reference range. Physical examination showed multiple dermabrasions on his face, abdomen, and lower extremities. All other examinations were unremarkable except that of mild abdominal pain. Laboratory results gave no clues. On abdominal x-ray, paucity of intestinal gas, pseudomass, and surrounding gas appearances were visible (Figure). Whole-body CT showed normal head and thorax findings, but there was a target sign in the axial view consistent with intussusception (Figure). In addition, coronal views demonstrated pseudokidney or the sandwich sign (Figure). The patient was taken to our trauma room; meticulous tertiary examinations were done. Two liters of normal saline was administered. No nausea or vomiting occurred during observation. His abdominal pain resolved gradually. On the 24th hour after admission, control CT showed that the findings of intussusception
disappeared. He was discharged after 1 day of observation. Outpatient follow-up did not show any abnormality. This is the first case report of an adult who had spontaneous reduction of ileoileal intussusception occurred after punching to the abdomen. The telescoping of the proximal intestinal segment into the adjacent distal intestinal segment is described as intussusception. It is more common in the children when compared to the adults, the etiology being generally idiopathic [2]. Although it is the most common cause of intestinal obstruction and the second most common cause of acute abdomen in pediatric age group, intussusception constitutes 1% to 5% of all intestinal obstructions of adulthood [3]. In adults, 80% of the cases have an underlying etiology, being different from children [2]. After the age of 18 years, tumors, polyps, edema and fibrosis of the intestinal wall due to surgical interventions, Meckel diverticulum, inflammation, postoperative adhesions, and intestinal sutures are the most frequently described causes [2-4]. Intussusception related to abdominal trauma is met very rarely [4]. In published studies, abdominal trauma was found as the etiological factor in only 0.7% to 1.96% of all adult patients having intussusception [5]. The risk of intussusception is higher in penetrating trauma when compared to the blunt injury [5]. Intussusception is generally seen after trauma associated with high-energy and multiple injuries [4,5]. However, in our case, it was observed as an isolated event, without any coexisting high-energy trauma or organ pathology. Although the mechanism of intussusception was not completely identified, the most probable mechanism seems to be local small intestinal spasm, following abnormal peristalsis, intramural hematoma, or edema, which develops after abdominal trauma [1,6]. The increased adrenergic discharge secondary to trauma increases the sympathetic activity in the gastrointestinal canal, leading to constriction of sphincters and segmental intestinal spasm. This situation may be another facilitator for intussusception [6]. Edematous intestinal segments, by increasing the intraperitoneal pressure, facilitate the intussusception of normal intestinal segments [6]. In our case, intramural hematoma or edema was not present in both the initial and in the control CTs. Therefore, the most probable pathophysiological mechanism seemed to be sympathetic hyperactivation, which is a physiological response. Of adult intussusceptions, 52% are seen in small intestine, whereas 38% are seen in colon. Enteroenteric intussusception, as in our case, is the most common type [7]. In intussusception, the clinical symptoms may start acutely or may progress insidiously over days or even weeks [3]. The complaints of the patients during admission are nonspecific and may manifest themselves in a wide clinical range [8]. The first imaging method is direct abdominal x-ray. Although ultrasonography is helpful in selected cases,
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Emet M, et al, Spontaneous reduction of ileoileal adult intussusception after blunt abdominal injury, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.07.053
2
M. Emet et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Figure. A, In direct supine abdominal x-ray, paucity of intestinal gas at left upper quadrant, pseudomass, and surrounding gas are observed. B, In contrast upper abdominal CT (axial view), the target sign showing telescoped ileal loops, consistent with ileoileal intussusception. C, In contrast upper abdominal CT (coronal view), pseudokidney or sandwich sign. D, In contrast upper abdominal CT (axial view), control CT obtained 24 hours later does not show any sign of intussusception (spontaneous regression).
abdominal CT is the most accurate radiological technique for confirmation of intussusception in adults [8,9]. In CT, the heterogeneous “target” or “sausage” shaped soft tissue image, which is formed by telescoping of intestines, is pathognomonic [7]. In published studies, the diagnostic accuracy of tomography is reported as 58% to 100% [8]. In various articles, patients whose clinical conditions were stable and tomographic findings were normal during the first admission but who developed intussusception within up to 16 days were reported [3,9]. Our case was different because there was a traumatic intussusception at the time of admission. Although the proximal intestinal segment telescopes into the distal segment, it pulls the mesentery together with itself and impairs the lymphatic and venous drainage. Therefore, if intussusception is not treated, it may lead to intestinal ischemia and/or perforation [9]. Untreated cases may have a fatal outcome [10]. The conventional treatment of symptomatic adulthood intussusceptions is explorative laparotomy or laparoscopy, followed by resection of the ischemic regions or leading masses which cause intestinal obstruction. Because of theoretical risks such as perforation, dispersion of tumor cells or intestinal microorganisms, and increased surgical complications related to the fragile and edematous structure of the manipulated intestinal segment, manual preoperative reduction by barium, air, or in the operating room is not recommended. In asymptomatic patients, no intervention is required [7]. Our patient was treated conservatively because no sign of acute abdomen was present. In conclusion, we suggest that, in patients with mild to moderate trauma, even if the patient has mild abdominal pain, physicians should rule out invagination. Computed tomography is the suggested imaging modality. These patients should be kept in close follow-up. If symptoms resolve and intussusception findings disappear in CT, no further treatment is required.
Mucahit Emet MD ⁎ Abdullah Osman Kocak MD Ilker Akbas MD Department of Emergency Medicine, Faculty of Medicine, University of Ataturk, Erzurum, Turkey ⁎Corresponding author at: Department of Emergency Medicine, Faculty of Medicine, University of Ataturk, 25240, Erzurum, Turkey Tel.: +90 532 1612 776; fax: +90 442 2363 133 E-mail addresses: [email protected] (M. Emet) [email protected] (A.O. Kocak) [email protected] (I. Akbas) Adem Karaman MD Department of Radiology, Faculty of Medicine, University of Ataturk Erzurum, Turkey E-mail address: [email protected] Sukru Arslan MD Department of General Surgery, Faculty of Medicine, University of Ataturk Erzurum, Turkey E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.07.053 References [1] Erichsen D, Sellstrom H, Andersson H. Small bowel intussusception after blunt abdominal trauma in a 6-year-old boy: case report and review of 6 cases reported in the literature. J Pediatr Surg 2006;41(11):1930–2. [2] Benjelloun el B, Ousadden A, Ibnmajdoub K, Mazaz K, Taleb KA. Small bowel intussusception with the Meckel's diverticulum after blunt abdominal trauma: a case report. World J Emerg Surg 2009;4:18 (e1-e3).
Please cite this article as: Emet M, et al, Spontaneous reduction of ileoileal adult intussusception after blunt abdominal injury, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.07.053
M. Emet et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx [3] Brooks A, Bebington BD, Lucas S, Oettle GJ. Intussusception caused by blunt abdominal trauma. J Trauma 1999;47(1):156–7. [4] Stockinger ZT, McSwain Jr N. Intussusception caused by abdominal trauma: case report and review of 91 cases reported in the literature. J Trauma 2005;58(1):187–8. [5] Komadina R, Smrkolj V. Intussusception after blunt abdominal trauma. J Trauma 1998;45(3):615–6. [6] Afifi I, Al-Thani H, Attique S, Khoschnau S, El-Menyar A, Latifi R. Delayed presentation of intussusception with perforation after splenectomy in patient with blunt abdominal trauma. Case Rep Surg 2013;2013:510701 (e1-e4).
3
[7] Lu T, Chng YM. Adult intussusception. Perm J 2015;19(1):79–81. [8] Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, et al. Intussusception of the bowel in adults: a review. World J Gastroenterol 2009;15(4): 407–11. [9] Wilson MA, Dubinsky TJ. Intussusception of a Meckel's diverticulum following blunt abdominal trauma. Curr Probl Diagn Radiol 2012;41(4):136–7. [10] Yang Z, Yang Z, Yan K, Williams S, Lew HL. An unusual cause of abdominal pain in a patient with severe traumatic brain injury (TBI): intussusception of the jejunum. Am J Phys Med Rehabil 2009;88(10):864–5.
Please cite this article as: Emet M, et al, Spontaneous reduction of ileoileal adult intussusception after blunt abdominal injury, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.07.053
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Spontaneous reduction of ileoileal adult intussusception after blunt abdominal injury Abstract This is the first case report of an adult who had spontaneous reduction of ileoileal intussusception occurred after punching to the abdomen. A 40-year-old man was brought to our emergency department by ground ambulance due to pounding and punching a few hours ago. Physical examination showed multiple dermabrasions on his face, abdomen, and lower extremities. All other examinations were unremarkable except that of mild abdominal pain. Laboratory results gave no clues. On abdominal x-ray, paucity of intestinal gas, pseudomass and surrounding gas appearances were visible. No nausea or vomiting occurred during observation. His abdominal pain resolved gradually. On the 24th hour after admission, control computed tomography showed that the findings of intussusception disappeared. He was discharged after 1 day of observation. Outpatient follow-up did not show any abnormality. We suggest that, in patients with mild to moderate trauma, even if the patient has mild abdominal pain, physicians should rule out invagination. Computed tomography is the suggested imaging modality. These patients should be kept in close follow-up. If symptoms resolve and intussusception findings disappear in computed tomography, no further treatment is required. Intussusception is common in early childhood. Intussusception due to blunt injury is rare and not predominant in the pediatric population. There are only a few adult cases [1]. Here, we present a 40-year-old man who was exposed to blunt abdominal trauma. He had moderate abdominal pain and computed tomography (CT) showed a “target” lesion that was specific for invagination. Abdominal CT revealed target sign in the axial view, and coronal views demonstrated pseudokidney or the sandwich sign. A 40-year-old man was brought to our emergency department by ground ambulance due to pounding and punching a few hours ago. He had no chronic illness and no drug or substance abuse. His vital signs were within reference range. Physical examination showed multiple dermabrasions on his face, abdomen, and lower extremities. All other examinations were unremarkable except that of mild abdominal pain. Laboratory results gave no clues. On abdominal x-ray, paucity of intestinal gas, pseudomass, and surrounding gas appearances were visible (Figure). Whole-body CT showed normal head and thorax findings, but there was a target sign in the axial view consistent with intussusception (Figure). In addition, coronal views demonstrated pseudokidney or the sandwich sign (Figure). The patient was taken to our trauma room; meticulous tertiary examinations were done. Two liters of normal saline was administered. No nausea or vomiting occurred during observation. His abdominal pain resolved gradually. On the 24th hour after admission, control CT showed that the findings of intussusception
disappeared. He was discharged after 1 day of observation. Outpatient follow-up did not show any abnormality. This is the first case report of an adult who had spontaneous reduction of ileoileal intussusception occurred after punching to the abdomen. The telescoping of the proximal intestinal segment into the adjacent distal intestinal segment is described as intussusception. It is more common in the children when compared to the adults, the etiology being generally idiopathic [2]. Although it is the most common cause of intestinal obstruction and the second most common cause of acute abdomen in pediatric age group, intussusception constitutes 1% to 5% of all intestinal obstructions of adulthood [3]. In adults, 80% of the cases have an underlying etiology, being different from children [2]. After the age of 18 years, tumors, polyps, edema and fibrosis of the intestinal wall due to surgical interventions, Meckel diverticulum, inflammation, postoperative adhesions, and intestinal sutures are the most frequently described causes [2-4]. Intussusception related to abdominal trauma is met very rarely [4]. In published studies, abdominal trauma was found as the etiological factor in only 0.7% to 1.96% of all adult patients having intussusception [5]. The risk of intussusception is higher in penetrating trauma when compared to the blunt injury [5]. Intussusception is generally seen after trauma associated with high-energy and multiple injuries [4,5]. However, in our case, it was observed as an isolated event, without any coexisting high-energy trauma or organ pathology. Although the mechanism of intussusception was not completely identified, the most probable mechanism seems to be local small intestinal spasm, following abnormal peristalsis, intramural hematoma, or edema, which develops after abdominal trauma [1,6]. The increased adrenergic discharge secondary to trauma increases the sympathetic activity in the gastrointestinal canal, leading to constriction of sphincters and segmental intestinal spasm. This situation may be another facilitator for intussusception [6]. Edematous intestinal segments, by increasing the intraperitoneal pressure, facilitate the intussusception of normal intestinal segments [6]. In our case, intramural hematoma or edema was not present in both the initial and in the control CTs. Therefore, the most probable pathophysiological mechanism seemed to be sympathetic hyperactivation, which is a physiological response. Of adult intussusceptions, 52% are seen in small intestine, whereas 38% are seen in colon. Enteroenteric intussusception, as in our case, is the most common type [7]. In intussusception, the clinical symptoms may start acutely or may progress insidiously over days or even weeks [3]. The complaints of the patients during admission are nonspecific and may manifest themselves in a wide clinical range [8]. The first imaging method is direct abdominal x-ray. Although ultrasonography is helpful in selected cases,
0735-6757/© 2015 Elsevier Inc. All rights reserved.
Please cite this article as: Emet M, et al, Spontaneous reduction of ileoileal adult intussusception after blunt abdominal injury, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.07.053
2
M. Emet et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx
Figure. A, In direct supine abdominal x-ray, paucity of intestinal gas at left upper quadrant, pseudomass, and surrounding gas are observed. B, In contrast upper abdominal CT (axial view), the target sign showing telescoped ileal loops, consistent with ileoileal intussusception. C, In contrast upper abdominal CT (coronal view), pseudokidney or sandwich sign. D, In contrast upper abdominal CT (axial view), control CT obtained 24 hours later does not show any sign of intussusception (spontaneous regression).
abdominal CT is the most accurate radiological technique for confirmation of intussusception in adults [8,9]. In CT, the heterogeneous “target” or “sausage” shaped soft tissue image, which is formed by telescoping of intestines, is pathognomonic [7]. In published studies, the diagnostic accuracy of tomography is reported as 58% to 100% [8]. In various articles, patients whose clinical conditions were stable and tomographic findings were normal during the first admission but who developed intussusception within up to 16 days were reported [3,9]. Our case was different because there was a traumatic intussusception at the time of admission. Although the proximal intestinal segment telescopes into the distal segment, it pulls the mesentery together with itself and impairs the lymphatic and venous drainage. Therefore, if intussusception is not treated, it may lead to intestinal ischemia and/or perforation [9]. Untreated cases may have a fatal outcome [10]. The conventional treatment of symptomatic adulthood intussusceptions is explorative laparotomy or laparoscopy, followed by resection of the ischemic regions or leading masses which cause intestinal obstruction. Because of theoretical risks such as perforation, dispersion of tumor cells or intestinal microorganisms, and increased surgical complications related to the fragile and edematous structure of the manipulated intestinal segment, manual preoperative reduction by barium, air, or in the operating room is not recommended. In asymptomatic patients, no intervention is required [7]. Our patient was treated conservatively because no sign of acute abdomen was present. In conclusion, we suggest that, in patients with mild to moderate trauma, even if the patient has mild abdominal pain, physicians should rule out invagination. Computed tomography is the suggested imaging modality. These patients should be kept in close follow-up. If symptoms resolve and intussusception findings disappear in CT, no further treatment is required.
Mucahit Emet MD ⁎ Abdullah Osman Kocak MD Ilker Akbas MD Department of Emergency Medicine, Faculty of Medicine, University of Ataturk, Erzurum, Turkey ⁎Corresponding author at: Department of Emergency Medicine, Faculty of Medicine, University of Ataturk, 25240, Erzurum, Turkey Tel.: +90 532 1612 776; fax: +90 442 2363 133 E-mail addresses: [email protected] (M. Emet) [email protected] (A.O. Kocak) [email protected] (I. Akbas) Adem Karaman MD Department of Radiology, Faculty of Medicine, University of Ataturk Erzurum, Turkey E-mail address: [email protected] Sukru Arslan MD Department of General Surgery, Faculty of Medicine, University of Ataturk Erzurum, Turkey E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.07.053 References [1] Erichsen D, Sellstrom H, Andersson H. Small bowel intussusception after blunt abdominal trauma in a 6-year-old boy: case report and review of 6 cases reported in the literature. J Pediatr Surg 2006;41(11):1930–2. [2] Benjelloun el B, Ousadden A, Ibnmajdoub K, Mazaz K, Taleb KA. Small bowel intussusception with the Meckel's diverticulum after blunt abdominal trauma: a case report. World J Emerg Surg 2009;4:18 (e1-e3).
Please cite this article as: Emet M, et al, Spontaneous reduction of ileoileal adult intussusception after blunt abdominal injury, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.07.053
M. Emet et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx [3] Brooks A, Bebington BD, Lucas S, Oettle GJ. Intussusception caused by blunt abdominal trauma. J Trauma 1999;47(1):156–7. [4] Stockinger ZT, McSwain Jr N. Intussusception caused by abdominal trauma: case report and review of 91 cases reported in the literature. J Trauma 2005;58(1):187–8. [5] Komadina R, Smrkolj V. Intussusception after blunt abdominal trauma. J Trauma 1998;45(3):615–6. [6] Afifi I, Al-Thani H, Attique S, Khoschnau S, El-Menyar A, Latifi R. Delayed presentation of intussusception with perforation after splenectomy in patient with blunt abdominal trauma. Case Rep Surg 2013;2013:510701 (e1-e4).
3
[7] Lu T, Chng YM. Adult intussusception. Perm J 2015;19(1):79–81. [8] Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, et al. Intussusception of the bowel in adults: a review. World J Gastroenterol 2009;15(4): 407–11. [9] Wilson MA, Dubinsky TJ. Intussusception of a Meckel's diverticulum following blunt abdominal trauma. Curr Probl Diagn Radiol 2012;41(4):136–7. [10] Yang Z, Yang Z, Yan K, Williams S, Lew HL. An unusual cause of abdominal pain in a patient with severe traumatic brain injury (TBI): intussusception of the jejunum. Am J Phys Med Rehabil 2009;88(10):864–5.
Please cite this article as: Emet M, et al, Spontaneous reduction of ileoileal adult intussusception after blunt abdominal injury, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.07.053