Intussusception is a serious condition in which part of the intestine (intussusceptum) enfolds into an adjacent part of the intestine (intussuscipiens).
As a result of this “telescoping”, obstruction, infarction and even perforation of the involved bowel segment may ensue. It often causes bowel obstruction in the paediatric population where the cause is most often idiopathic. Though rare in adults, most cases of adult intussusception are the result of an underlying medical condition such as a tumor.
In children, management is most often by an imaging technique (Barium enema) whereas in adults, surgery is usually required to correct the problem1. We present a case of an Idiopathic Ileo-ileal intussusception complicated by bowel obstruction, perforation and peritonitis. CLINICAL CASEA 45 y/o male farmer with no peculiar past history, was rushed into the outpatient department of our institution at 5pm on the 29th of December 2017 haven been referred from a remote health centre 2days before for proper management of an acute abdomen. History revealed an acute onset of mild to moderate abdominal 2days before while at home doing his regular chores.
Pains were cramping, intermittent, para-umbilical and non-radiating. Rapid progress of pains, becoming severe, persuaded him to consult at a nearby health centre where a tender para-umbilical abdominal mass was palpated and an acute abdomen suspected. He was given analgesics and referred for better management. Worsening of pains then ensued, this time steady, exacerbated by any movement and associated with repeated bouts of coffee ground vomiting and obstipation. Clinical assessment upon arrival revealed a prostrated patient in the lateral decubitus position with both knees flexed and screaming in anguishing pains. Vital parameters were as follows; 100/60mmHg for BP, 115bpm pulse and 38.5°C temperature. The abdomen was non distended, non- mobile with respiration, rigid (cardboard rigidity) with diffuse guarding.
Hernia orifices were not bulging and a rectal exam revealed an empty rectum with a tender Douglas pouch. Our clinical findings permitted us to pose as diagnosis, Peritonitis. A FBC done revealed an elevated white cell count at 17800 cells/µl with granulocytes predominating, further supporting our diagnosis. Other pre-op workups notably, Bleeding time, Clotting time, HIV serology and Creatinemia were unremarkable.
Given our findings we immediately counselled and got a signed consent to perform an exploratory laparotomy. We proceeded using the traditional midline incision. Intraoperatively, we found a pus-like fluid oozing out of the peritoneum immediately it was breached with intestinal exploration revealing a dilated portion of small intestine presenting an Ileo-ileal intussusception causing an obstruction and a single perforation on the Intussuscipiens (figure 1). The later was oedematous and getting friable probably the reason it got perforated. It was equally twisted on the mesenteries at its neck making reduction difficult (figure 1).As management, we ligated and cutted the mesenteries at the neck to permit reduction.
We then reduced the intussusception by gentle traction and retrograde pressure from the apex. This revealed a segment of necrotic bowel about 8cm long (figure 2 and 3). Finally we performed resection and Ileo-ileal anastomosis (figure 4). Elsewhere, there was no organomegaly or lymphadenopathy. Peritoneal lavage was done with lukewarm Saline, drain placed and abdomen closed. We placed the patient of routine Intravenous triple antibiotherapy, analgesics and fluids.
Post operatory follow up was unremarkable as oral sips were started on day 2 and drain removed during first wound dressing on day 5 postop. The patient was discharged on Day 10 after removal of stitches.