A N U N U S U A L C A S E O F I N T U S S U S C E P T I O N

AN UNUSUAL CASE OF INTUSSUSCEPTION

BY JAMES A. ROSS SURGEON, EDINBURGH ROYAL INFIRMARY; SURGEON, LEITH HOSPITAL

AND IAN C. K. TOUGH SURGICAL REGISTRAR, LEITH HOSPITAL

62 I

INTUSSUSCEPTION in the adult, though relatively uncommon compared with the condition in child- hood, is a well-known cause of 'acute abdomen'. Eliot and Corscaden (I~II), in whose classic paper 300 cases are cited; Christopher (1936); Donhausen and Kelly (I950), who collected 665 cases from British and American literature; and Brown and Michels (1952) have all given detailed accounts of the disease in the adult.

A recent case presenting certain unusual clinical and pathological features seems, however, to be worthy of comment.

CASE REPORT R. R., a 61-year-old dock labourer, for some months

previous to the onset of his acute symptoms had noted loss of appetite and had felt off colour. He had no pain, however, and there was no change in his bowel habit.

On Dec. 26, 1957, six days before admission to hospital, he carried out a household removal, and whilst lifting a wardrobe felt a sudden severe pain in his right iliac fossa. The pain eased off gradually and for the next few days, though still present, it did not trouble him unduly. He felt off his food, but he continued to do light work at the docks. The day before admission the pain in the right iliac fossa increased and then quite suddenly it travelled round and settled in the left side of the abdomen. There it persisted with variable intensity throughout the night, attacks lasting twenty minutes to three-quarters of an hour, till he was sent in to hospital on Jan. I, 1958.

During this period there had been no change in the bowel habit, the bowels having opened normally on the day before admission, and there had been no vomiting. The patient also thought that his urine had been blood- stained on a number of occasions during the previous two days. He had no other urinary symptoms.

ON EXAMINATION in hospital, R. was seen to be a pale, ill-looking man. Pulse, 128/min.; temperature, 102' F.; blood-pressure, I30/90. The abdomen, which was not distended, was markedly tender on the left side over an ill-defined palpable mass extending from the left iliac crest up towards the left costal margin and backwards into the left loin. There was no generalized tenderness and bowel-sounds were normal. Rectal examination was negative. Microscopical examination of the urine showed numerous red cells; culture of the urine was later shown to reveal only a scanty growth of coagulase-negative staphylococci. Diagnosis was considered to lie between diverticulitis of the descending colon and infected hydro- nephrosis, perinephric abscess, or a renal tumour.

The patient settled well after admission, the pain lessened, and the temperature fell to 98.8" F. The following day, however (Jan. 2), the pain increased and for the first time he vomited, though only a small amount. He vomited twice, again small amounts, the next day (Jan. 3) and the pain became severe. He continued to pass flatus per rectum. It was now possible to feel a hard well-defined lower pole to the mass originally noted, but the full extent of the mass was obscured by guarding. An intravenous pyelographic examination was carried out; this showed normal pyelograms, with both kidneys excreting.

The increase of the patient's symptoms, and some general deterioration in his condition, with the increased

prominence of the palpable mass in the abdomen, indicated exploration, and this was performed on the evening of Jan. 3.

AT OrERATIoN.-Anresthesia administered by Dr. I. MacIntyre was induced by 0.4 g. of half-strength thiopentane intravenously and maintained by cyclo- propane and oxygen in closed circuit from a Gillies machine, with 120 mg. of flaxedil as a relaxant. An oblique muscle-cutting incision was made in the left flank,

FIG. 71 1.-Drawing illustrating the condition seen at opera- tion. The sheath or intussuscipiens has sloughed and the intussusceptum is visible with a nodular carcinoma at its apex.

overlying the palpable mass. The tissues were noted to be edematous and the exploring finger went easily through the peritoneum into what appeared to be a large abscess cavity. The cavity, however, contained large quantities of green mucinous material and gas instead of pus; and lying exposed in it was a large sausage-like object, about 16 cm. long, covered with mucous membrane (Fig. 711). Further exploration showed that this protruded through a large defect in the descending colon, 5 cm. below the splenic flexure. This object lifted up easily, and a narrow band of the posterior wall of the colon was seen to lie posterior to it, extending down to the left iliac fossa, and there joining the lower part of the descending colon,

622 T H E B R I T I S H J O U R N A L O F S U R G E R Y

where the circumfereiice of the bowel became continuous agam. It was then recognized that the condition was an mtussusception; the sheath or intussuscipiens had evidently sloughed fcir 16 cm. in the descending colon, and the oblong mass was the intussusceptum. The intussusceptum itself, though edematous and congested, was viable and appcared to be clothed with colonic mucosa. At the apex was a nodular ulcerated area about 3 cm. in diameter, with the appearance of a carcinoma.

After suction of the escaped mucus, and swabbing the area with dettol swabs, the general peritoneal cavity was easily entered by the separation of light adhesions, and the intussusception was traced round to the hepatic flexure, where the ileim was seen to enter the reefed-up colon. The small intestine was only moderately dis- tended. An attempt to reduce the intussusception was unsuccessful and it was felt that there was no alternative but to proceed to radical measures. From the lower part of the oblique incision a vertical left paramedian incision was extended upwards. The intussusception, comprising the terminal ileum, caecum, ascending, transverse, and most of the descending colon, was then resected in continuity. The distal part of the ileum and the proximal end of the distal colon, divided through healthy colonic wall z cm. below the gaping hole in the lower part of the descending colon, was then stitched together for 8 cm. to form a spur, and brought out in the left iliac fossa through the lower end of rhe oblique incision, with Paul’s tubes inserted into both ends, fo1:iowing the usual Paul Mikulicz technique (Maingot, 1948). At the end of the operation, which lasted I+ hr., during which 800 ml. of blood were given, the patient W ~ S in good condition, the blood- pressure being 140/80.

PROGRESS.-He made a satisfactory recovery. He had 500 mg. terramycin iiitra~venously twice a day for three days, followed by 500 mg. by mouth four times a day for eight days. The ileostomy acted well. An enterotribe was applied to the spur on Jan. 17. The skin had become somewhat excoriated around the bowel opening, and on Feb. 18 the ileocolostomy was closed extraperitoneally. A small quantity of Faeces continued to be discharged through a tiny opening in the wound, though the bowels moved normally. On ,Mzy 15, this opening was explored. It was found that dense scar tissue had prevented a complete closure of the opening in the mucous membrane. The track between the skin and the intestine with the surrounding scar was excised, the opening in the bowel wall was closed, and ihe abdominal wall repaired. The wound healed soundly, and the patient went home on June 2.

THE SPECIMEN.-’rhe microscopical report on a section of the specimm was given by Professor E. C. Mekie, Conservator of the Royal College of Surgeons Museum, as follows (I:eb. 3): Section from the apex of the intussusceptum shows a papilliferous adenocarcinoma with considerable differentiation and in the section studied, very little infiltration. The picture is grossly distorted by marked edema, presumably due to the mechanical obstructions of the blood-supply occasioned by the intussusception.

D1 SCUSSION Two special features require discussion in this

case: (I) the clinical features; and (2) the uatho- , ,

logical findings. The Clinical Features.-The cardinal svm-

ptoms of intussuscep1:ion in both adults and children are: (I) periodic attacks of abdominal pain; (2) vomiting; (3) a palpable tumour in the abdomen; and (4) passage of blood per rectum. (Brown and Michels, 1952; Wangensteen, 1955.)

Eliot and Corscaden ( I ~ I I ) , however, state that the clinical picture in intussusception in the adult is

by no means constant; and other authorities have noted that the picture is less characteristic in the adult than in the child (Thomson, Miles, and Wilkie, 1931). Brown and Michels write, “The diagnosis of intussusception in the adult is frequently difficult”, and according to Donhauser and Kelly (1950) the symptomatology in cases of intussusception in the adult is so indefinable that a definite diagnosis can be made only rarely. Cases which have simulated other lesions such as cholecystitis or peptic ulcer have been described (Christopher, 1936). Moreover, in contrast to other forms of bowel strangulation, intussusception, at least in the earlier phases, may occur without localized tenderness or muscle spasm owing to the fact that the strangulated segment, the intussuscep- tum, is ensheathed by the intussuscipiens, which thereby protects the parietal peritoneum from irritation (Nichols, 1941).

Eliot and Corscaden state that those intussuscep- tions due to malignant tumours may present in one of three ways: (I) An acute onset in a previously healthy patient (uncommon); (2) A history of a primary growth in a distant part of the body (usually a sarcoma) precedes the intussusception; (3) A history of chronic obstructive symptoms, intus- susception being suggested by the presence of a palpable mass. This is the commonest type.

There may be varying degrees of intussusception -acute, subacute, and chronic-there may therefore be a history suggestive of recurrent attacks of bowel obstruction, symptoms being present for a period of days or years. In Brown and Michels’s (1952) 15 cases the average duration of symptoms was eight months.

The striking clinical feature of the present case is the onset of pain in the right iliac fossa, where the intussusception originated, followed by a clear history of the pain travelling round to the left side of the abdomen. This travelling of pain in intussuscep- tion has been noted by Wangensteen (I955), and there can be little doubt that the pain in the present case was caused by the actual development of the intussusception. A muscular strain may start the onset of intussusception, as Eliot and Corscaden (1911) have described, and this had occurred in the present case also; but the significance of this feature was not appreciated at the time.

When the mass developed in the left groin, intussusception was still not considered; the transient haematuria focused attention on the kidney as a possible cause of the swelling, the pyrexia being considered consistent with a renal condition. Absence of obstructive bowel symptoms till the day of opera- tion was also misleading, there being at no time the characteristic blood or mucus in the stools. Intus- susception not being suspected, Dance’s sign- emptiness of the right lower quadrant of the ab- domen (Ferrer, 1950)-was not sought after. When operation was eventually decided upon, the diagnosis rested tentatively between (I) diverticulitis with paracolic abscess, (2) carcinoma of the colon with paracolic abscess, and (3) perinephric abscess.

Pathology.-The pathology of intussusception is well described by many authors. The great percentage of primary intussusceptions in the adult are of the ileo-ileal, ileocaecal, and ileocolic types (Donhauser and Kelly, 1950), and the present case

A N U N U S U A L C A S E O F I N T U S S U S C E P T I O N 623

falls into the category of ilrocolic, or perhaps more correctly colocolic.

In the majority of cases the intussusception is single, and descending in direction, though more complicated types have been described (Walton, 1911). In the adult, intussut,ception is usually due to an organic cause. In Eliot and Corscaden's (1911) series there were 60 instancis of benign tumour and 40 of malignant tumour. In Dionhauser and Kelly's series (1950) malignant turnours were the cause of the intussusception in 20 per cent of the whole series.

The obstruction in intussusception is afforded by the active contraction of the sheath, especially at its neck. An actual block of the lumen does not exist. The continuity of the intestinal lumen between proximal and distal segments remains intact, and in chronic intussusceptions in which the bowel wall changes are not as marked, the intestinal current is preserved. The greatest alteration in the bowel in acute intussusception occurs in the intussusceptum (Wangensteen). The vessels in the mesentery becoming constricted, the intussusceptum and the reflected layer become edematous and swollen, and if the constriction at the neck of the intussuscipiens is tight, the circulation in the intussusceptum may be entirely arrested and gangrene may ensue (Watson- Cheyne and Burghard, 1913).

If untreated, the condition progresses; the gangrenous intussusceptum becomes a slough. The spontaneous evacuation of this gangrenous intus- susceptum, composed of vs rying lengths of small intestine, czcum, and colon, has been frequently described, particularly in older literature (Hutchinson, 1874, quoted by Close, I931 Gould and Pyle, 1897; Eliot and Corscaden, 1911; Nichols, 1941). In the days before routine abdominal surgery such cases were thus occasionally cured spontaneously, though some died later of obstruction due to stenosis of the bowel.

The intussuscipiens, or sheath, on the contrary, rarely shows significant gross changes (Walton, 191 I ; Bockus, 1944; Wangensteen, 1955). It is not in- frequently congested, or it may exhibit deposits of fibrin or other evidence of local peritonitis. Wangen- steen observes that it may occasionally even perforate consequent upon pressure of the invaginated bowel upon it. In Eliot and Corscaden's 300 cases it is recorded that in one the intussuscipiens was in a condition of incipient gangrene, and in a second (Case 223) at operation the in-ussuscipiens was found split; but we have been unable to find a reference to gross sloughing of the intussuscipiens similar to that in the present case. We consider that the cause of this necrosis of the ensheathing bowel was probably the pressure of the bulky intiissusceptum producing an interference of the blood-supply of the colon wall; the colon, in contrast with the small intestine, being a comparatively avascular scructure (Ross, 1952). The intussusceptum, though congested, was quite

viable; the sloughing of the enclosing sheath evidently relieved pressure on it, though it was still tightly gripped proximally, and eventually would have become gangrenous.

That this sloughing of the sheath for at least 16 cm. should be unassociated with gross contamina- tion of the peritoneal cavity is a remarkable feature of the present case. The explanation would appear to be, first, that the colon had emptied itself after the process of intussusception began, as shown by the con- tinuation of normal bowel movements up to the day before admission. Secondly, the intussusceptum, continuing to swell after the sheath had burst, became so tightly gripped as it passed through the bowel at the upper end of the tear that no further faxal matter passed through. The clinical history and operative findings suggest that complete obstruction was of only short duration.

The operative treatment requires no special comment. We considered that there was no alter- native to the radical procedure adopted, which fortunately proved successful.

SUMMARY A case of intussusception of the colon in a man

aged 61 is described with: (I) Unusual clinical features ; (2) Gross pathological changes. The sheath had sloughed for 16 cm., leaving the intus- susceptum free in the abdominal cavity, but with minimal soiling of the peritoneum.

Resection of the affected intestine proved suc- cessful.

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