Small bowel intussusception with the Meckel's diverticulum after blunt abdominal trauma: a case report
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Intussusception with the Meckel's diverticulum is a rare but well-known cause of small bowel obstruction in the adult. After blunt abdominal trauma, intussusception is exceedingly rare and has been reported previously only in few cases. We present a case of a previously healthy 28-year-old man developing four days after blunt abdominal trauma signs of small bowel obstruction. Ileo-ileal intussusception was suggested by computed tomography. Exploration revealed ileo-ileal intussusception with Meckel's diverticulum. A diverticulectomy with small bowel resection was performed.
KeywordsIntussusception Small Bowel Obstruction Blunt Abdominal Trauma Lead Point Solid Organ Injury
Intususception is invagination of a proximal segment of bowel (intussusceptum) into the lumen of the adjacent distal segment (intussuscipiens). While intusussception is relatively common in the childhood, it is infrequently seen in adults . Whereas most cases in childhood occur idiopathically, in adults, an underlying cause is present in 80% of cases . Causes include tumours and polyps as well oedema and fibrosis from recent or previous surgery, and Meckel's diverticula. Cases following blunt abdominal trauma are rare. We present a case of 28-year previously healthy man presenting with abdominal pain and vomiting after blunt abdominal trauma, and developing four days later signs of small bowel obstruction as a cause of ileoileal intussusception with the Meckel's diverticulum. From an extensive review of the literature, intussusception at the site of a Meckel's diverticulum following blunt abdominal trauma has not been previously reported.
Intussusception is defined as the telescoping of one segment of the gastrointestinal tract into an adjacent one. It is relatively common in children and is the second most common cause of an acute abdomen in this age group. It is much less common in adults and accounts for less than 5% of cases of mechanical small bowel obstruction .
However, blunt abdominal trauma is an unusual cause and only a few isolated cases reports are available in the literature. The underlying mechanism of traumatic intussusception is unknown but has been proposed to be a pathological peristaltic wave and/or localized spasm of a bowel segment after the trauma . Another possible mechanism could be an intramural hematoma or edema acting as a lead point.
Meckel diverticulum is the commonest within a large number of lead points of structural, vascular/hematological, neoplastic, or inflammatory character . In our case we think that the focal lead point was a Meckel's diverticulum, but a trauma with disturbed bowel motility was the unlatching mechanism of intussusception.
Adults will have a variable presentation of intussusception, often with a chronic colicky pain and intermittent partial intestinal obstruction associated with nausea and Vomiting , Because of this variable presentation, the diagnosis is often late.
An experienced hands ultrasound has both high sensitivity and specificity in the detection of intussusception. Classic findings on transverse scanning include a so-called "target lesion" or "doughnut sign", with the presence of several concentric rings . CT is important in diagnosing associated pathology such as lymphadenopathy, it is often not very successful in determining the specific cause of the intussusception, as the lead point in many cases is small and often hidden within the intussuscepted mass .
All adult patients with intussusception will therefore require laparotomy. Resection is indicated in cases of large bowel intussusception, but reduction without resection may be an option in cases of small bowel involvement where the incidence of malignancy is not great and no abnormality of the small intestine is observed .
In conclusion, intussusception, although rare, should be considered when patients with blunt abdominal trauma present with insidious signs of obstruction.
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