Ileo–ileal intussusception as an unusual cause of obscure overt gastrointestinal bleeding

A 20-year-old man arrived at the emergency department with a 1-day history of melena and one episode of lipothymia. He had no medical history and was not taking any medication. Significant findings on physical examination included an arterial blood pressure of 90/40 mmHg, paleness of his mucosae and skin, and melena on rectal digital examination. Laboratory analysis revealed normocytic normochromic anemia (6.7 g/dL) and an elevated urea level (9.4 mmol/L).

He was treated with fluid therapy and packed red blood cell transfusion. An upper gastrointestinal endoscopy was performed, which was normal. A colonoscopy with terminal ileoscopy showed the presence of blood in the colon and terminal ileum, without any mucosal changes. Scintigraphy with ^99 mTc-pertechnetate did not show any positive findings. A capsule enteroscopy identified a large polypoid formation with congested and ulcerated mucosa in the proximal ileum ([Fig. 1]; [Video 1]), which caused a delay in capsule progression. Blood traces without active bleeding were identified.

Fig. 1 Endoscopic appearance of a large polypoid formation in the proximal ileum with congested and ulcerated mucosa.

Capsule enteroscopy revealed a large polypoid formation with congested and ulcerated mucosa in the proximal ileum, which caused a delay in capsule progression.

The multidisciplinary team decided to perform an exploratory laparotomy. An ileal invagination in the proximal ileum was identified and a segmental enterectomy was performed ([Fig. 2]). Macroscopic examination revealed an ileal invagination in the ileal lumen forming an intraluminal polypoid lesion of 7 cm. Microscopic examination showed large necrotic areas and mucosal ulceration at the top of the invaginated segment ([Fig. 3]). No tumor tissue was identified. The patient remained asymptomatic 1 year later.

Fig. 2 The resected surgical specimen showing an ileo–ileal intussusception.

Fig. 3 Histological appearance showing large necrotic areas and mucosal ulceration at the top of the invaginated segment.

Intussusception is a rare clinical condition in adults [1]. It may be secondary to intraluminal or extraluminal lesions [2], but 8 % – 20 % of cases are idiopathic [3]. The majority of patients present with symptoms of bowel obstruction [4]. Intussusception is often misdiagnosed and the majority of cases are diagnosed intraoperatively [5]. We report a case of idiopathic ileo–ileal intussusception that presented with obscure overt gastrointestinal bleeding and emphasize the role of capsule enteroscopy, which allowed presurgical visualization of the lesion.

Endoscopy_UCTN_Code_CCL_1AB_2AH_3AB

• References

• 1 Lianos G, Xeropotamos N, Bali C et al. Adult bowel intussusception: presentation, location, etiology, diagnosis and treatment. G Chir Vol 2013; 34: 280-283
• 2 Lu T, Chng Y. Adult intussusception. Perm J 2015; 19: 79-81
• 3 Teixeira D, Martins M, Costa V et al. Idiopathic bowel intussusception in adults: case report. Rev Port Cir 2013; 27: 107-112
• 4 Batista N, Maximiano LF. Intestinal intussusception in young adults – literature review. Rev Col Bras Cir 2009; 36: 533-536
• 5 Athanasios M, Anneza Y, Lazaros S et al. Intussusception of the bowel in adults: a review. World J Gastroenterol 2009; 15: 407-411