|Year : 2013 | Volume
| Issue : 1 | Page : 26-28
Adult jejunoileal intussusception caused by inflammatory fibroid polyp
Basant M Singhal, Virendra Kumar, Sumendhankar Sagar, Chandra P Singh
Department of Surgery, Lala Lajpat Rai Memorial Medical College, Merrut, Uttar Pradesh, India
|Date of Acceptance||15-Oct-2013|
|Date of Web Publication||14-Feb-2014|
Basant M Singhal
Post Graduate Department of Surgery, Lala Lajpat Rai Memorial Medical College, Garh Road, Meerut - 250 004, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Inflammatory fibroid polyp (IFP) is a rare non-neoplastic condition, which has been reported to cause gastrointestinal (GI) bleeding and simple mechanical obstruction of the pylorus or small intestine, but rarely intussusception. Only 1-5% of all bowel obstructions in adults are due to intussusception; >90% of cases are associated with lead point lesions. We are presenting a rare case of adult intussuception caused by an IFP as a lead point lesion. Computed tomography (CT) scan is the investigation of choice for diagnosis of intussusception as well as to identify benign or malignant nature of lead point lesions. En bloc resection of the involved bowel, without attempt at reduction, is the recommended surgical procedure for adult intussusception.
Keywords: Jejunoileal intussusception, inflammatory fibroid polyp, intestinal obstruction
|How to cite this article:|
Singhal BM, Kumar V, Sagar S, Singh CP. Adult jejunoileal intussusception caused by inflammatory fibroid polyp. Niger J Surg Sci 2013;23:26-8
| Introduction|| |
Inflammatory fibroid polyp (IFP), first described by Vanek  in 1949, is a rare non-neoplastic condition of unknown etiology with maximum incidence in 6 th decade of life. It may affect any portion of the gastrointestinal (GI) tract, commonest site being the stomach followed by the small intestine and rarely occur in the large intestine or esophagus.  IFP has been reported to cause GI bleeding and simple mechanical obstruction of the pylorus or small intestine, but rarely cause intussusception. 
Intussusception is a relatively rare condition in adults and it is an entirely different clinical entity from the pediatric intussusception, both etiologically as well as for the management.  It represents 1-5% of all bowel obstructions in the adults and 5% of all cases of intussusceptions. , Adult small bowel intussusception due to IFP has been reported but rarely. , We are reporting a rare case of adult jejunoileal intussusception due to IFP in the jejunum.
| Case History|| |
A 51-year-old male presented with a history of recurrent generalized, colicky postprandial abdominal pain for 4 months. These attacks of pain were at times associated with nausea and vomiting, but there was no history of alteration in bowel habits, bleeding per rectum, and any urinary or systemic symptom. The patient was nondiabetic and there was no history of tuberculosis or previous abdominal surgery. The contour of the abdomen was normal with no tenderness or palpable mass on clinical examination. Abdominal roentgenograph revealed there was dilatation of the small bowel with a shadow suggestive of a mass in upper pelvis. On abdominal sonography, this mass was having bowel within bowel appearance raising the possibility of the intussusception. On further evaluation by double contrast computed tomography (CT) scan, there was a 58 × 28 × 29 mm, smooth, oval, and heterogeneously enhancing mass of jejunoileal intussusception (bowel within bowel appearance) [Figure 1]. There was a thickening of a long segment of the jejunum proximal to this intussusception.
|Figure 1: Double contrast computed tomography scan showing intussusception (arrow), with proximal dilation of jejunum|
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On laparotomy, there was a jejunoileal intussusception of about 14 cm length involving the distal jejunum and proximal ileum. Jejunum proximal to this intussusception was grossly dilated. En bloc resection of the intussuscepted mass was done followed by a jejunoileal anastomosis. The postoperative period was uneventful and the patient was discharged on 10 th postoperative day.
Macroscopically, in the lumen of resected jejunum, there was a polyp measuring 30 × 28 × 25 mm [Figure 2]. In the adjacent bowel, there was loss of mucosal rugosities and few ulcerated areas. On histopathological analysis of the polyp, there was marked inflammation in all layers of the bowel wall with eosinophilic infiltration and marked proliferation of fibroblasts.
| Discussion|| |
Adult intussusception is a rare but well-recognized condition which is associated with a lead point lesion in >90% of cases. , Clinical presentation of the adult intussusception is usually insidious and the most consistent symptom being recurrent colicky abdominal pain of long duration, which may be associated with nausea, vomiting, abdominal distension, constipation, and diarrhea. , Abdominal mass is palpable in only 7-42% of the patients and 20% of patients may present in the emergency room with acute intestinal obstruction.  Other uncommon presentations may be long duration painless intussusceptions associated with tuberculosis abdomen or lower GI bleed. 
Approximately two-thirds of adult intussusceptions arise in the small bowel and lead-point lesions are responsible for 80% of cases.  In the small bowel lead-point lesions, approximately 65% are neoplastic (42.25% benign, 9.75% malignant). 
Diagnosis of the adult intussusceptions at times may be demanding due to atypical symptoms. On plain X-ray abdomen and upper GI barium studies, there may be an 'air crescent sign' due to trapped intraluminal layer of gases between walls of intussuscepted segment of bowel or 'stacked coin' or 'coil spring appearance'.  In experienced hands, abdominal sonography is useful with classical imaging features being 'target sign' and 'doughnut sign' on transverse view, as well as "pseudokidney sign' and 'hayfork sign' on longitudinal view. ,
CT scan is the imaging method of choice for diagnosis in recurrent abdominal pain, with sensitivity and specificity being in the range of 58-100%, for diagnosis of the adult intussusception. , Characteristic imaging features on CT scan are, an inhomeogenously enhancing, 'target or sausage' shaped soft tissue mass with layering effect.  Additional advantage of CT scan is, its ability to identify and characterize the lead point lesion, as well as to evaluate this lesion and rest of the abdomen for presence of malignancy. 
Surgery is the treatment of choice for adult intussusception and en bloc resection of the bowel involved in the intussusception is recommended, as 40-60% lead-point lesions turn out to be malignant. ,,, Most of the authors agree that attempt at reduction, at the time of surgery has theoretical disadvantage of peritoneal, intraluminal, and venous dissemination of malignant cells as well as virulent bowel microorganism. In addition, pressure of manipulation of friable and edematous bowel during manual reduction may also increase risk of anastomotic complications. ,,, If malignancy is suspected, formal resection with adherence to oncologic principles is recommended.  However, reduction of intussuscepted bowel segment may be done with intent to limit the extent of resection if a benign etiology of lead-point lesion can be safely established by preoperative investigations or there is a risk of leaving a short bowel. 
This is a relatively rare case of adult intussusception caused by an IFP as a lead point lesion. Abdominal sonography was useful in initial diagnosis of intussusception, which was confirmed by CT scan.
| Conclusion|| |
It is important that surgeons should have a high index of suspicion for intussusception in the adult patients, who present with chronic intermittent symptoms of subacute intestinal obstruction, as a significant majority of cases are associated with malignancy. En bloc resection of the involved bowel without attempt at reduction is the recommended surgical intervention.
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[Figure 1], [Figure 2]