Presentation
2 weeks of severe abdominal pain around umbilical area radiating to the iliac fossae bilaterally. Known small periumbilical hernia, previous epigastric hernia repair. White cell count mildly raised, CRP normal.
Patient Data
CT abdomen and pelvis
Appearance of small bowel intussusception in the left lower quadrant over length approximately 9 cm though no associated small bowel obstruction, impression of fullness within the small bowel lumen raises the possibility of an associated mass lesion but this is not definite. Normal large and small bowel appearances otherwise, with normal enhancement.
No free gas, no free fluid nor collection.
Small hypoattenuating foci in the liver are likely benign, liver is otherwise normal.
Small areas of calcification in the kidneys bilaterally may be vascular in nature or represent pyramidal calcification, overall doubtful significance. No urinary tract calculi demonstrated. Kidneys otherwise normal.
Normal gallbladder, adrenals, pancreas and spleen.
Surgical clips in the anterior abdominal wall epigastric region. Very small fat-containing periumbilical hernia.
No size significant abdominal or pelvic nodal enlargement.
The celiac axis, superior mesenteric artery and superior mesenteric vein are relatively well opacified.
Opinion:
Short segment small bowel intussusception in left lower quadrant though no bowel obstruction, possible intraluminal mass associated with the intussusception.
Possible penetrating duodenal ulcer, would recommend direct visualization.
Annotated images to highlight the key findings.
Case Discussion
Given the length of time of the symptoms, the subjective severity of the abdominal pain and the positive radiological finding of small bowel intussusception decision was made to proceed to diagnostic laparoscopy.
Intra-operatively the small bowel intussusception spontaneously reduced, however a small mass lesion was palpable, the nature of which was unclear at the time of surgery. Short segment small bowel resection and anastomosis was undertaken.
The subsequent histopathology demonstrated a grade 1 well differentiated neuroendocrine tumor (ki-67 index 2%), margins clear despite the non-oncological resection.
The patient was discussed at the local neuroendocrine multidisciplinary team meeting. An Octreotide scan has been arranged, and upper GI endoscopy to evaluate the duodenal ulcer is pending.
Small bowel intussusception in adults often can be transient and non-symptomatic/incidental particularly if in the jejunum, though a lead point should always be assessed for.