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Answer: Acute Intussusception
Figure 1 Computed tomographic scan of the abdomen, showing "bowel within bowel," typical of intussusception.
Figure 2 Operative picture after the intussusception had been reduced. Note the dimple in the terminal ileum (indicated by the hemostat), the site of an invaginated Meckel diverticulum (as shown in the inset). This was the main point of intussusception.
A 20-YEAR-OLD, emaciated man came to the emergency department with recurrent right lower quadrant pain and diarrhea. The patient had been having similar episodes for the past 5 years and was seen in several hospitals. He had recently been referred to a psychiatrist for these symptoms. A physical examination revealed a thin, cachectic individual, underdeveloped for his age, with tenderness in the right lower quadrant without peritoneal signs. A vague "fullness" was appreciated in the right upper quadrant. Laboratory results were within normal limits. A computed tomographic scan was obtained (Figure 2).
The abdominal computed tomographic scan indicated an intussusception starting in the ileum and progressing toward the transverse colon. On operation, the terminal ileum was found intussuscepting into the cecum up to the transverse colon. This was carefully reduced. The terminal ileum was dusky and ecchymotic and showed an area of dimpling, with a palpable mass within the lumen. This was resected, and an ileo-ileostomy was performed. The operative specimen showed an invaginated, gangrenous Meckel diverticulum that acted as the lead point for the intussusception (Figure 2). On histopathologic examination, the Meckel diverticulum was infarcted and perforated, with gastric foveolar metaplasia. The patient recovered uneventfully and, at last follow-up, was gaining weight rapidly.
In a 1978 Japanese literature review of 600 patients with Meckel diverticulum, intussusception was reported in 13.7% of 287 symptomatic patients.1 In adults, intussusception is secondary to small bowel tumors, polyps, or Meckel diverticulum. The signs and symptoms are vague and, as in this patient, chronic, recurrent abdominal pain due to attacks of intussusception may be misdiagnosed as a psychiatric disorder. The radiologic features on computed tomography are suggestive, as demonstrated by this patient. In a 30-year experience reported from Massachusetts General Hospital (Boston),2 there were 58 cases of surgically proven adult intussusception. Ninety-three percent of the intussusceptions were associated with a pathologic lesion; 44% with an enteric lesion; and 14% with a colonic lesion. Forty-eight percent of the enteric lesions were malignant and 52% were benign. This report concluded that surgical resection of the intussusception without reduction is the preferred treatment in adults.
Corresponding author: Rao R. Ivatury, Department of Surgery, Virginia Commonwealth University Health System, 1200 E Broad St W15E, Richmond, VA 23298.
Image of the Month—Diagnosis. Arch Surg. 2003;138(6):682. doi:10.1001/archsurg.138.6.681
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