Case Report

Contents lists available at ScienceDirect

American Journal of Emergency Medicine

journal homepage: locate/ ajem

American Journal of Emergency Medicine 32 (2014) 490.e1-490.e3

Successful treatment of ileocolic intussusception with air Enema reduction in an adult patient?

Abstract

Intussusception is a Rare condition in adults, representing only 1% of all Bowel obstructions. In adult cases, operative explorations are recommended to treat the bowel obstruction and to diagnose underlying diseases. The objective of the current case report was to describe the successful treatment of ileocolic intussusception with air enema reduction in an adult patient. A previously healthy 21-year-old woman had a 20-hour history of colicky abdominal pain and vomiting and was diagnosed as having idiopathic ileocolic intussusception by Abdominal computed tomography. We treated the patient with air enema reduction under fluoroscopic guidance instead of an operative procedure. She received oxygen and intravenous midazolam to provide some degree of pain relief. Air was carefully pumped manually into the rectum, and the air pressure was monitored with a manometer. Because of air leakage from the rectum through the void to the outside the body, we continued to provide air to maintain the air pressure between 40 and 60 mm Hg. Three minutes after initiation of the air enema, when the patient experienced increasing abdominal pain and vomiting, the pressure was temporarily increased to greater than 100 mm Hg, and the air reached the terminal ileum. We considered the reduction successful and con- firmed it with an Abdominal ultrasound examination. We believe that air enema reduction is effective for treating idiopathic intussuscep- tion within 24 hours of symptom onset in young, previously healthy adult patients.

Intussusception is the invagination of one portion of the alimentary tract into an adjacent segment [1]. It is the most common cause of intestinal obstruction in infants and young children; however, it is a rare condition in adults, representing only 1% of all bowel obstructions [2]. Intussusception can be categorized into 4 types according to its location, that is, enteric, ileocecal, ileocolic, and colocolic [3]. In children, the intussusception type is most often ileocolic, and there are usually no recognizable Lead points for the intussusception [1,4]. Conversely, the organic lesions that lead to the intussusception are generally located in adult patients [5]. Therefore, operative explorations are recommended in adult cases to prevent or treat the resultant bowel obstruction and to diagnose underlying diseases.

A previously healthy 21-year-old woman was transferred to our emergency department and admitted to the hospital. She had a 20-hour history of colicky abdominal pain, nausea, and vomiting. At

? Conflicts of interest and source of funding: None declared.

an outside facility, she was diagnosed as having an acute intussusception by abdominal computed tomography (CT; Fig. 1A). On arrival, she was alert and had a blood pressure of 155/93 mm Hg and oxygen saturation of 98% on room air. She denied having abdominal injuries such as a bruise. On physical examination, she displayed right lower quadrant abdominal tenderness without peritoneal signs; however, no Abdominal mass, skin rash, or purpura was detected. Abdominal CT obtained 4 hours after the initial survey revealed that the ileocolic intussusception had progressively dete- riorated into the transverse colon; however, no mass was evident in the lesion (Fig. 1B). We diagnosed the patient with ileocolic intussusception without a recognizable lead point. After we obtained informed consent from the patient and her parents, we started treatment with air enema reduction under fluoroscopic guidance [1]. She received oxygen and intravenous midazolam to provide some degree of pain relief. Air was carefully pumped manually into the rectum, and the air pressure was monitored with a manometer (Fig. 2). Because of air leakage from the rectum to the outside the body, we continued to administer air to maintain the air pressure between 40 and 60 mm Hg. Three minutes after initiation of the air enema, when she experienced increasing abdominal pain and vomiting, the pressure was temporarily increased to greater than

100 mm Hg and then the air reached the terminal ileum. We considered the reduction successful and confirmed it with an abdominal ultrasound examination. Subsequently, her general condition gradually improved. There was no evidence of malignancy or other disease on the examinations. One week later, she was discharged from the hospital. Her condition remains good, and there has been no recurrence of the intussusception.

Intussusception in adults is a rare condition, even in the emergency setting [6,7]. Because a pathological lead point exists in most cases of adult intussusception, emergency laparotomy is recommended for diagnostic therapy [8,9]. However, Onkendi et al

[3] recently reported that idiopathic intussusception accounts for 30% of all adult intussusception and suggested that intussusceptions lacking a pathological cause of obstruction on CT are likely self- limiting and do not require operation.

Intussusception is the most common cause of intestinal obstruc- tion in children between the ages of 3 months and 6 years, and typical intussusception is treated by reduction via an enema, which should be performed immediately after the diagnosis. The most appropriate choice of contrast media for enema reduction under fluoroscopy\air or liquid\has been debated [10,11]. Recently, air enema reduction was considered more likely to successfully treat intussusception than hydrostatic reduction in children [1,12]. Moreover, the former is associated with fewer complications and lower radiation exposure

0735-6757/$ - see front matter (C) 2014

490.e2 S. Matsui et al. / American Journal of Emergency Medicine 32 (2014) 490.e1-490.e3

Fig. 1. A, Coronal CT of the patient showing ileocolic intussusception with no evident lead point. B, Four hours later, ileocolic intussusception had progressively deteriorated into the transverse colon.

than the latter and thus should be the method of choice for treatment [4]. Based on our experience with the present case, air enema reduction, even for adult patients, has some strong advantages in addition to the aforementioned points. It is easy to use and inexpensive and does not require a large amount of hydrostatic contrast medium, even if leakage from the body exists. However, it has some drawbacks. First, the implementation of air enema should be arranged in advance. Fig. 2 shows the air enema reduction kit that we use for infants and children in our institution. It was suitable for our patient’s build (height and body weight, 165 cm and 60 kg, respectively). Second, the fluoroscopic field may be relatively narrow for adult patients to observe the air distribution in the entire abdomen. Finally, emergency physicians probably are not familiar with the air enema reduction procedure.

We believe that air enema reduction is effective for treating intussusception within 24 hours of symptom onset [4] in young, previously healthy adult patients with no pathological lead points detected on CT. Therefore, emergency physicians and surgeons should be familiar with air enema reduction as a potentially effective procedure for idiopathic intussusception in adults.

Fig. 2. Air enema reduction kit used for infants and children in our institution. The kit consists of a urethral catheter (22F) with an inflatable balloon (volume, b30 mL), tubes and connectors, a T-shaped stopcock, a manometer, and a manual pressurizer. It was suitable for our patient’s build (height and body weight, 165 cm and 60 kg, respectively).

Satoshi Matsui, MD Takashi Kanemura, MD

Department of Critical Care Medicine and Traumatology

Disaster Medical Center

Tokyo, Japan

Yukako Yokouchi, MD, PhD Department of Pediatrics Disaster Medical Center

Tokyo, Japan

Hideo Kamiichi, MD Department of Gastroenterology Disaster Medical Center

Tokyo, Japan

Nobuaki Kiriu, MD

Department of Critical Care Medicine and Traumatology

Disaster Medical Center

Tokyo, Japan

Yuji Koike, MD, PhD Department of Pediatrics Disaster Medical Center

Tokyo, Japan E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.11.017

References

1. Ito Y, Kusakawa I, Murata Y, et al. Japanese guidelines for the management of intussusception in children, 2011. Pediatr Int 2012;54:948-58.
2. Azar T, Berger DL. Adult intussusception. Ann Surg 1997;226:134-8.
3. Onkendi EO, Grotz TE, Murray JA, et al. Adult intussusception in the last 25 years of modern imaging: is surgery still indicated? J Gastrointest Surg 2011; 15:1699-705.
4. Kennedy M, Liacouras CA. Intussusception. In: Kliegman RM, et al, editor. Nelson textbook of pediatrics. 19th ed. Philadelphia: Elsevier; 2011. p. 1287-9.
5. Cochran AA, Higgins 3rd GL, Strout TD. Intussusception in traditional pediatric, nontraditional pediatric, and adult patients. Am J Emerg Med 2011;29:523-7.
6. Amoruso M, D’Abbicco D, Praino S, et al. Idiopathic adult colo-colonic intussusception: case report and review of the literature. International Journal of Surgery Case Reports 2013:416-8.

   S. Matsui et al. / American Journal of Emergency Medicine 32 (2014) 490.e1-490.e3 490.e3

   Hanan B, Diniz TR, da Luz MM, et al. Intussusception in adults: a retrospective study. Colorectal Diseases 2010;12:574-8.

7. Frydman J, Ben-Ishay O, Kluger Y. Total ileocolic intussusception with rectal prolapse presenting in an adult: a case report and review of the literature. World Journal of Emergency Surgery 2013;8:37-40.
8. Singhal S, Singhal A, Arora PK, et al. Adult ileo-ileo-caecal intussusception: case report and literature review. Case Reports in Surgery 2012. http://dx.doi.org/10.1155/2012/789378.
9. Phelan E, de Campo JF, Malecky G. Comparisons of oxygen and barium reduction of ileocolic intussusception. Am J Roentgenol 1988;150:1349-52.
10. Meyer JS. Air and liquid contrast agent in the management of intussusception: controlled, randomized trial. Radiology 1993;188:507-11.
11. Beres AL, Baird R. An institutional analysis and systemic review with meta- analysis of pneumatic versus hydrostatic reduction for pediatric intussusception. Surgery 2013;154:328-34.