Insidious presentation of intussusception with appendicitis

A very rare case of ileocolic and appendiceal intussusception with acute appendicitis

Intussusception is a common cause of bowel obstruction in children, typically occurring in those under 3 years old and often idiopathic. Secondary intussusception is less common in pediatric patients and usually involves a pathological lead point. Appendiceal intussusception is rare, occurring in only 0.01% of appendectomy specimens, and can mimic other acute abdominal conditions, making preoperative diagnosis challenging. We report a case of a 7-year-old male who presented with a 3-day history of crampy right lower quadrant pain and nonbilious vomiting. Ultrasound revealed an ileocolic intussusception with a suspected pathological lead point. Further imaging identified a distended, non-compressible appendix within the intussusceptum, leading to a diagnosis of secondary ileocolic intussusception due to acute appendicitis. Hydrostatic reduction was initially successful, but the patient developed recurrent intussusception within 24 hours. Surgical exploration confirmed McSwain type 3 appendiceal intussusception, necessitating manual reduction and appendectomy. The patient recovered well postoperatively. Clinicians should maintain a high index of suspicion for appendiceal pathology in older children with intussusception, and thorough imaging evaluation is essential. Early recognition of an inflamed appendix as the lead point is critical to prompt appropriate surgical intervention, ultimately preventing further complications. This case contributes to clinical practice by emphasizing the need for tailored diagnostic and therapeutic strategies in managing rare, complex presentations of intussusception.

The Many Faces of Intestinal Tumors in Adults, Including the Primary Role of CT Imaging in Emergencies and the Important Role of Cross-Sectional Imaging: A Pictorial Review

Background/Objectives: Small bowel tumors (SBTs) encompass a diverse range of tumor types, with benign tumors being the most prevalent. However, the incidence of malignant SBTs is increasing, particularly small bowel adenocarcinoma; this poses a diagnostic challenge for clinicians and radiologists due to the varied and nonspecific clinical and radiological presentations associated with SBTs. In fact, SBTs can present differently in emergencies, often mimicking inflammatory diseases or manifesting as complications such as intussusception, small bowel obstruction (SBO), intestinal ischemia, perforation, gastrointestinal bleeding, or metastatic disease. These tumors can remain asymptomatic for extended periods. Methods: We present a pictorial review on the role of imaging in evaluating SBTs, focusing on the emergency setting where diagnosis can be incidental. We also include some representative cases that may be useful for radiologists and residents in clinical practice. Results: Despite these challenges, contrast-enhanced computed tomography (CECT) is usually the best modality to use in emergencies for evaluating SBTs, and in some cases, a diagnosis can be made incidentally. However, when possible, multimodal imaging through cross-sectional imaging remains crucial for the non-invasive diagnosis of SBTs in stable patients, as endoscopic procedures may also be impractical. A complementary CT study with distension using negative oral contrast media, such as water, polyethylene glycol, or mannitol solutions, can improve the characterization of SBTs and rule out multiple SBT locations, particularly in small bowel neuroendocrine tumor (NET) and gastrointestinal tumor (GIST) localization. Positive water-soluble iodine-based oral contrast, such as Gastrografin (GGF), can be used to evaluate and monitor the intestinal lumen during the nonsurgical management of small bowel obstruction (SBO) or in suspected cases of small bowel perforations or the presence of fistulas. Magnetic resonance enterography (MRE) can aid in improving the characterization of SBTs through a multiplanar and multisequence study. Positron emission tomography combined with CT is generally an essential modality in evaluating metastatic disease and staging and assessing tumor prognosis, but it has limitations for indolent lymphoma and small NETs. Conclusions: Therefore, the integration of multiple imaging modalities can improve patient management and provide a preoperative risk assessment with prognostic and predictive indicators. In the future, radiomics could potentially serve as a "virtual biopsy" for SBTs, allowing for better diagnosis and more personalized management in precision medicine.

Intussusception of the cecum due to the acute appendicitis: A case report

Introduction and importance

Intussusception of the cecum due to acute appendicitis is rare condition.

Presentation of case

A 17-year-old male patient presented to our hospital with a chief complaint of right lower abdominal pain, which had lasted for two days. Computed tomography (CT) revealed a “target sign” from the cecum to the ascending colon, leading to a diagnosis of cecocolic intussusception. Colonoscopy revealed an erythematous, edematous, and internally distorted cecum in the ascending colon, which was difficult to repair with air insufflation. Laparoscopic surgery was performed to remove the bowel obstruction. Repositioning of the invaginated cecum was difficult due to the presence of a hard and edematous colic wall. Therefore, laparoscopic ileocecal resection was performed to release the obstruction. The pathological diagnosis was appendicitis and abscess within the cecum wall, with no malignant findings.

Discussion

In our case, intussusception was considered to have caused thickening of the intestinal wall of the cecum due to inflammation of the appendix, and the thickened area became the leading point.

Conclusion

Considering that malignancy is a frequent leading point in adult patients with intussusception, a preoperative endoscopic examination is important for minimizing bowel resection.

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Most cases of intussusception outside of childhood are caused by tumors, but inflammation of the appendix or cecum can be a cause.

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If malignancy is not the cause of intussusception, bowel resection can be minimized.

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In order to determine the appropriate extent of resection, an accurate preoperative diagnosis is necessary, keeping in mind the possibility that appendicitis or inflammatory changes in the cecum may be the leading point.