Adult Small Bowel Intussusception -
Rush University Medical Center. Chicago, IL

A 23 year old woman with a past medical history significant for ovarian cysts presented to our institution with a one day history of multiple bouts of non-bloody, non-bilious emesis unrelated to meals. Additionally, she reported a “building pressure” type of non-radiating epigastric pain prior to emesis with relief upon vomiting. On further questioning, she reported mild constipation, but no diarrhea, fevers, sick contacts, or prior episodes of similar symptoms. She felt entirely normal prior to the onset of these symptoms. She denied any prior surgical history, medication usage, or allergies. Family history was positive only for diabetes and she smoked one pack per day of cigarettes with moderate social alcohol usage. On exam, she was afebrile with normal vital signs. Her abdominal exam was significant for a scaphoid appearance, the absence of surgical scars, and mild tenderness in the left upper quadrant to deep palpation without masses or hernias discovered. Bowel sounds were present on auscultation.

Laboratory values were significant for a leukocytosis of 13,000 with a left shift and an elevated urinary specific gravity.

A CT of the abdomen and pelvis was obtained which revealed two loops of bowel with a “bulls-eye” type appearance. She was unable to tolerate oral contrast.

Based upon her history and physical exam plus leukocytosis and these CT findings, an exploratory laparoscopy with a possible bowel resection was offered to the patient.    In the operating room, she was placed under general anesthesia and three 5mm ports were placed and the small bowel examined from the ligament of Treitz to the cecum. The abnormality identified on CT scan was identified as a small bowel intussusception located approximately two feet from the ligament of Treitz. The bowel did not appear to be dilated proximal to the intussusception. A periumbilical incision was made and the intussuscepted segment of small bowel delivered from the abdomen and resected. The bowel was reanastomosed with staplers and returned to the abdomen. No other abnormalities were identified and the operation was completed. Postoperatively, her hospital course was uneventful.

The specimen pathology was reported as a congested segment of small bowel with moderately increased intraepithelial lymphocytes without villous atrophy, masses, or diverticula. This suggests that the lymphatic tissue within the wall of the small bowel may have been the lead point for the intussusception.

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