Letters to the Editor

Ileoileal Intussusception with a Leading Meckel's Diverticulum



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Am Fam Physician. 1998 Sep 1;58(3):659-660.

to the editor: Intussusception most commonly affects infants between the ages of five and nine months,13 but it may also occur in older children, teenagers and adults. The etiology is usually unknown in infants; older children and adults, however, often have lead points13 such as a Meckel's diverticulum, intestinal polyps, neoplasms and foreign bodies.3 First-hand treatment of this condition is hydrostatic desinvagination.4 When this treatment is inappropriate or unsuccessful, surgical reduction is necessary.4 We report on two girls suffering from ileoileal intussusception with a leading Meckel's diverticulum.

The first case involved a 12-year-old girl with episodic, intermittent cramping abdominal pain over several years who was admitted to the surgical emergency department with lower abdominal pain. Previously she had been admitted for overnight observation and evaluation for appendicitis. At that time her symptoms subsided so no operation was performed. At the time of this admission, she presented with intense right lower quadrant tenderness on abdominal palpation. Despite normal laboratory values and the absence of fever, she was scheduled for appendectomy. At laparotomy, her appendix was normal in appearance. However, ileoileal intussusception with a Meckel's diverticulum as a lead point was found. The diverticulum was extirpated. Histologic analysis revealed a Meckel's diverticulum with some ectopic gastric mucosa. When contacted 14 months after the operation, the patient declared that she had not experienced any abdominal pain since the operation.

The second case involved an 18-year-old woman who presented with a history and clinical findings quite similar to those of the first case. Perioperative findings and the postoperative course, including histologic analysis and personal communication, were identical to those of the first case 13 months after the operation.

Intussusception is a fairly common disease in small children, but is considered rare in the adolescent or adult patient . After encountering the two reported cases, we question whether the incidence of ileoileal intussusception may be underestimated in adolescents. The fact that the two patients had a long history of episodes of abdominal pain, similar to the pain on the day of admission, makes it probable that they had actually suffered from several previous intussusceptions that perhaps resolved spontaneously.

Digital rectal examination is mandatory in the evaluation of acute abdomen. Still, the value of digital rectal examination is somewhat limited in patients with intussusception, since not all patients with this condition will present with grossly bloody stools. However, since occult blood evaluation is frequently positive, combining this examination with testing for occult blood will increase the sensitivity.5 Ultrasound of the abdomen is the examination of choice for diagnosis of intussusception. It is a simple and well-tolerated examination, with good sensitivity.6

Hopefully this letter may serve as a reminder that although ileoileal intussusception may not be a common condition in adolescents and adults, it should be considered in cases with unexplained, recurrent abdominal pain.

REFERENCES

1. Stringer MD, Pablot SM, Brereton RJ. Paediatric intussusception. Br J Surg. 1992;79:867–76.

2. Gierup J, Jorulf H, Livaditis A. Management of intussusception in infants and children: a survey based on 288 consecutive cases. Pediatrics. 1972;50:535–46.

3. Pollack CV Jr, Pender ES. Unusual cases of intussusception. J Emerg Med. 1991;9:347–55.

4. West KW, Stephens B, Vane DW, Grosfeld JL. Intussusception: current management in infants and children. Surgery. 1987;102:704–10.

5. Losek JD, Fiete RL. Intussusception and the diagnostic value of testing stool for occult blood. Am J Emerg Med. 1991;9:1–3.

6. Bhisitkul DM, Listernick R, Shkolnik A, Donaldson JS, Henricks BD, Feinstein KA, et al. Clinical application of ultrasonography in the diagnosis of intussusception. J Pediatr. 1992;121:182–6.

Send letters to Kenneth W. Lin, MD, MPH, Associate Deputy Editor for AFP Online, e-mail: afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680.

Please include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the American Academy of Family Physicians permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.



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