Background
Intussusception in adults is distinct from pediatric intus-susception in many aspects. Adult intussusceptions always demonstrate an etiology and malignant neoplasms which account for 40% [1,2] of for intussusception.
While adenocarcinoma, particularly metastatic carcinoma, is found to be the most frequent cause in the colon, primary adenocarcinoma, gastrointestinal stromal tumors, lymphoma, and carcinoid tumors are seen in the small intestine [3].
The gastrointestinal tract is the most common extra nodal site affected by lymphoma, accounting for 5%-20% of all cases. Histopathologically, almost 90% of primary gastrointestinal lymphomas are B-cell non- Hodgkin’s lymphomas (NHL), followed by T-cell NHL and Hodgkin’s lymphomas. Even though small intestinal tumors account for only 2% of gastrointestinal system tumors, lymphomas account for 10%-20% and 20%-30% of all primary gastrointestinal lymphomas. The ileum is the most common site affected by small intestine lymphomas, followed by the jejunum and duodenum. While intussusception is a very rare presentation of NHL, the most common lymphoma causing intussusception is diffuse large B-cell NHL [4,5].
We are reporting a rare case of Ileocolic intussusception in a 44-year-old man caused by Diffuse large B-cell lymphoma (DLBCL).
Case Presentation
A 44-year-old male patient with no significant past medical history presented with complaints of colicky abdominal pain with melena, loss of appetite and loss of weight. The patient was admitted with abdominal pain, distension and vomiting, and was found to have a right-sided abdominal mass of size 10 × 8 cm which was firm, nontender, mobile and intra-abdominal. He was evaluated with contrast enhanced computerised tomography (CECT) abdomen and clinical diagnosis of ileocolic intussusception due to neoplastic growth in the caecum was established.
CECT abdomen and pelvis revealed circumferential thickening of caecum and proximal ascending colon for 5 cm with telescoping of the distal ileum and ileocaecal junction junction into proximal caecum suggestive of ileocaecal intussusception (Figure 1) with large-sized adjacent mesenteric lymph nodes.
He was optimized in view of obstruction and was operated on and per operatively showed an ileocecal intussusception with prominent Lymph nodes (Figure 2). He underwent radical right hemicolectomy for intestinal obstruction based on the above-mentioned findings.
Macroscopic evaluation revealed a large polypoid lesion in the ileocecal junction with intussusception (Figure 3) and the histopathological evaluation and immuno histo chemistry revealed it as a case of DLBCL (Figure 4). The patient had an uneventful recovery and was discharged and is on follow-up.
Discussion
Intussusception is defined as the telescoping of a proximal bowel into the lumen of the adjacent segment. It is a rare cause of acute abdomen in adults and 75% of the cases are due to a malignant tumor in the small bowel or colon. Adult intussusception occurs more frequently in the small bowel (50%-88%) than in the large bowel (12%-50%) [6]. The common cause of intussusception occurring in the small intestine in adult is adenocarcinoma in up to 30% of the cases.
Colon adenocarcinoma is the most important cause of malignant large bowel intussusception. Lymphomas are also reported as tumoral masses inducing intestinal invagination rarely and up to 13% of colonic intussusception cases remain unexplained. However, in the literature review, Primary gastrointestinal lymphomas are rated second in terms of those leading to intussusception [7].
According to the World Health Organization classification NHL lymphomas fall into one of the six categories: extranodal marginal zone mucosa-associated lymphoma tissue (mucosa associated lymph tissue lymphoma), follicular lymphoma, mantle cell lymphoma, diffuse large B-cell lymphoma, and Burkitt’s lymphoma [8] .There are less than 50 Cases of DLBCL presenting as ileocolic intussusception even though in children the has been documented cases of Burkitt’s lymphoma presenting as ileo colic intussusception [9].
In the Surgical treatment of adult intussusception in the large bowel and ileocolic region, it is more likely that the intussusception will have a malignant etiology (up to 68%), and a resection without reduction is recommended. Surgical procedures performed about oncological principles are sufficient, while others support that addition of chemotherapy to surgery increases survival. Generally, chemotherapy is recommended along with surgery in cases with poor prognostic factors [10].
Conclusion
Ileocolic intussusception in adults is usually caused by malignancy and mostly as Adenocarcinoma. Non-Hodgkin lymphoma as a lead point is extremely rare and is usually a histologic surprise. However, a radical en mass resection without reduction is ideal in all forms of Adult colo colic and ileocolic intussusception.
What is new?
While intussusception is a very rare presentation of NHL, the most common lymphoma causing intussusception is diffuse large B-cell. In this rare case, ileocolic intussusception in a 44-year-old man was caused by diffuse large B-cell lymphoma (DLBCL). Less than 50 cases have been reported in the literature of ileocolic intussusception due to lymphoma.