International Journal of StudentS’ ReSeaRch Volume 2 Issue 1 Year 2012 www.ijsronline.com 18 CASE SERIES Diaz-Rosales et. al. Int J Stud Res 2012;2(1):18-20 Adult intussusception by tumor in ileum: a diagnostic dilemma Juan de Dios Diaz-Rosales, Lenin Enriquez-Dominguez, Jose R Castillo-Moreno, Pedro G Gutierrez-Ramirez Introduction The intussusception exists when a proximal segment of bowel (intussusceptum) telescopes into the lumen of the adjacent distal segment (intussuscipiens) [1]. Although it is very common in pediatric population (1-4 cases by 1000 live births), this entity is rare in adults (1-3 cases by each millions of habitants by year), and represents 1% of patient with bowel obstructions and 5% of all intussusceptions [2]. In this report, we present two cases of ileo-colic intussusceptions in adults, both with a pre-operative diagnosis of complicated acute appendicitis and post- operative diagnosis of intussusception by a distal ileal tumor. Case Presentation Case 1 An 18-year-old Mexican male, without pathologic medical history was admitted in the emergency room (ER) of General Hospital of Ciudad Juarez (México) with abdominal pain syndrome. He had a fifteen-day history of abdominal cramping pain (mild to moderate severity) in inferior right quadrant (IRQ); nausea and vomiting, hyperthermia, and malaise were present at the time of presentation. He was treated by his family physician with analgesics and antibiotics without improvement, and the symptoms persisted and the pain became severe and intractable. On examination, the patient was conscious, alert and oriented. He was afebrile with a heart rate (HR) of 92 beats per minute, respiratory rate (RR) 26 cycles per minute and blood pressure (BP) of 100/70 mmHg. Abdominal examination revealed a mass in the in Right Lower Quadrant (RLQ). McBurney’s sign, Psoas sign and Obturator sign were positive. Blood work up showed raised white blood cell count at 11,680 per mm 3 . Other hematological parameters were unremarkable. Plain abdominal films demonstrated signs of intestinal obstruction, air-fluid levels in small bowel and absence of air in the large bowel. Ultrasonography revealed a mass in the RLQ, and evidence of free fluid in lower abdomen. The pre-operative diagnosis of acute appendicitis and Meckel´s diverticulum was made. The patient underwent an emergent median laparotomy. During the operation, an ileo-ceco-colic intussusception was found; during reduction, a small mass into the ileal lumen was discovered. It was located in the region of distal ileum (Figure 1A). A right hemicolectomy with resection of affected ileal segments (approximately 20 cm) was performed. The continuity of the digestive tube was reestablished by primary double-layer end-to-end ileum- transvers anastomosis with 3.0 silk and 3.0 polyglactin 910. The anatomical pathology report revealed a submucosal tumor of the ileum, about 3 cm x 3 cm, with features of non- Hodgkin lymphoma (intermediate grade) (Figure 2A). The post-operative period was uncomplicated and he was discharged on the 7 th day following surgery. At the time of discharge, his presenting symptoms resolved and was referred to the oncology service for further assessment. Figure 1 Gross image. A: Case 1- Mass resected from the ileal lumen. B: Case 2- Transoperative enterotomy of ileum showing a polypoid mass in the inner of the lumen Case 2 A 25-year-old Mexican female, without pathologic medical history was admitted in the ER of our hospital with abdominal pain syndrome. The patient presented with a three-day history of abdominal discomfort with intermittent abdominal cramping pain of mild to moderate in severity, and localized around the mesogastric area, and progressed gradually into a severe pain with radiation to the right iliac quadrant. She also had nausea accompanied by 3 episodes of vomiting. She was afebrile with stable vital signs. Examination revealed a distended abdomen with rigidity and guarding with raised local temperature. An abdominal mass was palpated in the RLQ; Rovsing and Giordano signs were Department of Surgery, Hospital General De Ciudad Juarez, Universidad Autonoma De Ciudad Juarez, Mexico Corresponding Author Juan de Dios Diaz-Rosales, Email: juandedios_uacj@yahoo.com.mx ABSTRACT Intussusception in adults is an infrequent cause of intestinal obstruction; preoperative diagnosis is difficult as symptoms can be intermittent and long standing. This relatively rare entity differs from the childhood form in its etiology, presentation and treatment. We present two cases of ileo-colic intussusception in adults, with a clinical presentation that mimicked complicated appendicitis. These cases remind us that both ileal tumors and intussusception must be included in the diagnosis of lower abdominal pain. Key Words: Intussusception, carcinoid tumor, non-Hodgkin lymphoma, ileocecal valve.