Case Communications IMAJ • VOL 11 • January 2009

Ileocolic Intussusception in an Adult Patient due to a Cecal Fecalith Ahmad Mahajna MD and Michael M. Krausz MD

Department of Surgery A, Rambam Medical Center and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel

diagnosed as a cecal fecalith that terminal ilieum and the cecum into Key words: ileocolic intussusception, cecal had been already demonstrated 3 the ascending colon was found and fecalith, abdominal computed months previously in a CT scan right hemicolectomy was performed tomography, intestinal obstruction [Figure B] that had been per- due to the intracted bowel. The post- IMAJ 2009;11:58–59 formed following an abdominal stab operative course was uneventful and wound to the left upper quadrant. the patient was discharged from the Intussusception was diagnosed and hospital 8 days following surgery. ntussusception is a relatively com- an exploratory laparotomy was car- The diagnosis of a fecalith causing I mon cause of intestinal obstruction ried out. An intussusception of the an ileocecal intussusception was in children but a rare clinical entity in [A] CT demonstrating a round lesion in the confirmed by pathology. adults, representing less than 1% of right abdomen consisting of thickened intestinal obstructions in this patient bowel walls with eccentric low density population. The diagnosis of intus- mesenteric fat (short arrow) within it and Comment susception in the adult is difficult due an intraluminal mass forming a target The term intussusception refers to a to the variability of the symptoms. In appearance (arrow). spontaneous invagionation of an intes- up to 90% of cases an organic lesion A tinal segment into another bowel loop. inside the invaginated part of the bowel Invagination of small bowel was first is found to be the cause of this situa- described in 1674 by Paul Barbette tion. The majority of these lesions are [1], and the term intussusception was benign tumors. We present a rare case first coined in 1789 by John Hunter. It of ileocolic intussusception caused by a is a well-known entity in the pediatric cecal fecalith, which was diagnosed by population and is considered to be computed tomography. the most common cause of intestinal obstruction, occuring most frequently in infants under the age of 1 year. Patient Description Intussusception in adults is a rare A 21 year old previously healthy male entity and challenges the surgeon presented with colicky abdominal because of the wide range of issues that pain and nausea of 3 days durtion. [B] CT demonstrating an intraluminal mass need to be considered for establishing within the cecum (arrow) Physical examination revealed full- the etiology and therapeutic strategy. ness and tenderness of the right lower B Intussusception in adults presents with abdomen without signs of peritoneal a variety of acute, intermittent and irritation. Laboratory studies includ- chronic symptoms, thus making its ing temperature and complete blood preoperative diagnosis difficult. Unlike count were normal. Plain abdominal children, in whom a specific cause is X-ray was normal. Abdominal CT identified in fewer than 10% of cases, in demonstrated a round lesion in the adults an associated pathology (benign right abdomen consisting of thick- or malignant tumor, inflammation, ened bowel walls with eccentric adhesion, or diverticulum) is found in low density mesenteric fat (short 90% of cases. Begos et al. [2] in their arrow) within it [ Figure A], and an series found that the majority of adult intraluminal mass forming a target intussusception cases were of the small appearance (arrow). This mass was intestine, secondary to benign lesions.

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Primary or idiopathic intussusception mandatory. Early diagnosis is essential susception. Diagnosis can be deter- occurred in only 8% to 20% of cases to avoid a delay in treatment, which can mined radiologically and CT remains [3]. Primary or metastatic malignant increase morbidity and mortality. In the the method of choice. Surgical treat- lesions of the small intestine may occur early 20th century, Ladd [4] published ment and resection of the involved sec- in 6–30% of cases. Among these, meta- the first illustration of a diagnostic con- tion of the bowel permanently resolves static melanomas, carcinomatosis and trast enema in a child with intussuscep- the problem. leiomyosarcomas have been described. tion and suggested that this would be a When intussusception occur in the useful diagnostic procedure. Nordentoft Correspondence Dr. M.M. Krausz large bowel, a malignant etiology is [5] reported 500 patients, indicating the Dept. of Surgery A, Rambam Medical Center more frequent. Adenocarcinoma is the value of barium enema in the diagno- P.O. Box 9602, Haifa 31096, Israel leading cause. sis and treatment of intussusception. Phone: (972-4) 854-2782 Fax: (972-4) 854-3273 Review of the literature did not With advances in radiology, diagnosis email: m_Krausz @rambam.health.gov.il reveal any description of ileocolic intus- of adult intussusception can be made susception caused by a cecal fecalith. reliably with non-invasive imaging References Intussusception may be enteric, ileo- techniques. The use of CT as the first 1. Barbette P. Oeuvres chirurgiques a colic, ileocecal, or colonic. Several pos- imaging modality in the evaluation of anatomeques. Geneva: FrancoisMiege, 1674: 5221. sible mechanisms have been proposed patients with abdominal complaints has 2. Begos DG, Sandor A, Modlin IM. The diagnosis to explain this situation: a) a tumor may greatly expanded over the last few years. and management of adult intussusception. act as a foreign body causing violent CT is now considered to be the modal- Am J Surg 1997; 173: 88–94. peristalsis, so that the central part of ity of choice for the diagnosis of intus- 3. Sclarovsky-Benjaminov F, Wilson S, Habal F. Adult celiac disease presenting with intussus- the bowel easily moves into the dilated susception in adults, but ultrasound ception and elevated liver enzymes. distal part; b) intussusception may be and magnetic resonance imaging have IMAJ 2003; 5: 203–4. due to altered muscle function caused also been used effectively. In our case 4. Ladd WE. Progress in the diagnosis of intus- susception. by a tumor or bowel paralysis; and c) a CT acurately suggested ileocecal intus- Boston Med Surg J 1913; 168: 542–4. tumor may be grasped and pulled for- susception caused by an intraluminal 5. Nordentoft JM. The value of barium enema in ward by traction. Because of the high lesion. the diagnosis and treatment of intussusception in children, illustrsted by about 500 Danish likelihood of associated bowel pathol- In conclusion, cecal fecalith is an cases. ogy, surgical intervention in adults is extremely rare cause of ileocolic intus- Acta Radiol 1943; 24: 484–8.

Capsule

Natural antibodies against phosphorylcholine as potential protective factors in SLE ardiovascular diseases (CVD) are common among pa- ies were significantly decreased among SLE patients with Ctients with systemic lupus erythematosus (SLE). CVD and without CVD compared to healthy controls. In the low- and the presence of atherosclerotic plaques are associated est 25th percentile of anti-PC antibodies SLE patients with with traditional and non-traditional risk factors such as in- CVD were significantly more prevalent compared with SLE creased levels of oxidized low density lipoprotein (oxLDL) patients with no-CVD. Anti-PC-antibodies were negatively and increased inflammation. oxLDL is one of the impor- associated with SLE activity as defined by organ damage tant immune-stimulatory antigens in the atherosclerotic score (SLICC) and disease activity score (SLEDAI). One of plaque. Many of the pro-inflammatory effects of oxLDL are the mechanisms by which anti-PC antibodies exert their caused by phospholipids generated during LDL oxidation, protective role was also studied, by extracting anti-PC one of which, phosphorylcholine (PC), is also a ligand to antibodies from pooled human IgG (IVIG). The extracted the platelet-activating-factor (PAF)-receptor, which further anti-PC antibodies inhibited PAF-induced endothelial acti- promotes atherosclerosis. Natural anti-PC antibodies, es- vation, determined by expression of adhesion molecules. pecially of the immunoglobulin M subclass, were reported Together, these findings suggest that decreased anti-PC to be cardioprotective antibodies. Recently, Su et al. com- antibodies might lead to CVD in SLE patients, as these an- pared three age-matched groups for the presence of anti- tibodies seem to exert an anti-inflammatory cardioprotec- PC and other autoantibodies. The three groups included tive role. 26 SLE patients with a history of CVD, 26 SLE patients with Rheumatology 2008;47:1144 no-history of CVD and 26 healthy controls. Anti-PC antibod- Nancy Agmon-Levin

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