A Unique Case of Self-Resolving Multiple Intestinal Intussusceptions Concurrent with Inflammatory Gallbladder Polyps in an Adult

A Unique Case of Self-Resolving Multiple Intestinal Intussusceptions Concurrent with Inflammatory Gallbladder Polyps in an Adult | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A Unique Case of Self-Resolving Multiple Intestinal Intussusceptions Concurrent with Inflammatory Gallbladder Polyps in an Adult Haris Mumtaz Malik, Beenish Sabir, Doreen Macherera Mukona, Shafaq Saleem, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4495026/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Intestinal intussusception is the inversion of a portion of the proximal part of intestinal loop into the distal part of the loop. It leads to intestinal obstruction and vascular compromise. This predicament is rare in adults and is usually associated with benign or malignant neoplasms but very rarely with Gallbladder polyps. Case presentation: We present a case of a 41 year old male, presenting with abdominal pain, alternating episodes of diarrhea and constipation and gaseous abdomen for the preceding 5 months. Patient had pallor of mucosa, no jaundice, normal scaphoid shaped and non-tender abdomen and unremarkable head and neck. On complete blood count (CBC) the patient had decreased hemoglobin and raised lymphocytes. Multiple gut intussusceptions were observed in 4 areas and multiple echogenic foci were also observed in the gallbladder. Laparoscopic cholecystectomy showed a densely adherent gallbladder. On exploratory laparotomy no intussusceptions were seen at the indicated areas but rather abnormal constrictions of the gut which indicated past intussusceptions, suspected to have spontaneously healed without intervention. Conclusion: Intestinal Intussusceptions rarely occur in adults and are almost always accompanied by benign or malignant neoplasms. They rarely with illnesses such as gallbladder polyps. However, possibilities remain so these should not be ruled out without proper investigations. Proper follow up should therefore, be done owing to the possibility of recurrence. intussusception gall bladder polyps laparoscopic surgery Figures Figure 1 Figure 2 Figure 3 Background Intestinal intussusception is the inversion of a portion of the proximal part of the intestinal loop within the distal part of the loop ( 1 ). The pathophysiology includes altered bowel peristalsis at the intraluminal lesion, which serves as a lead point for intussusception ( 2 ). Intussusception is a rare, but potentially life-threatening disease more common in children than adults with an incidence of 1–3 cases per 1,000,000 population each year ( 3 , 4 ). Most patients present with non-specific symptoms such as generalized abdominal pain and vomiting, hence the diagnosis is often missed leading to complications such as intestinal obstruction and vascular compromise ( 5 , 6 ). Half of these cases are diagnosed during exploratory laparotomy or any other surgical operations while some are diagnosed with some diagnostic modalities such as plain abdominal film, ultrasound, and abdominal CT scan ( 7 – 9 ). More than 90% of intussusceptions in children are idiopathic while 70–90% in adults are secondary to an underlying gut wall disease. Among these cases in adults, more than 65% are caused by benign or malignant neoplasms ( 10 ), with the remainder of cases being secondary to non-specific processes (15–25%) and idiopathic causes (less than 10%) ( 11 – 13 ). In more than 90% of cases, intestinal intussusception occurs due to well-definable underlying gastrointestinal tract (GIT) pathology. These include malignancy, adenomas, lipomas, post-op adhesions, leiomyomas, Meckel’s diverticulum, lymphoid enlargement, celiac disease, cytomegalovirus (CMV) infection, or inflammatory fibroid polyps. Gallbladder polyps are non-motile mucosal elevations, protruding from the gallbladder mucosa into the lumen ( 14 ). These sessile pedunculated mucosal elevations are categorized as either pseudo- or true polyps. True polyps are usually adenomas of the gallbladder mucosa and may potentially be malignant. They can also be benign, including lipomas, fibromas, leiomyomas, or malignant, including lymphoma, and mesenchymal neoplasms, which are rarer than common adenomas. On the other hand, pseudopolyps are benign and include cholesterol foci, inflammatory polyps, or adenomyomatosis ( 14 , 15 ). There is scanty literature on the concurrence of multiple intestinal intussusceptions with inflammatory gallbladder polyps. However, to our knowledge, there is no previous case of spontaneous healing of intestinal intussusceptions reported with surgical interventions being done in almost all the cases. This case report presents a unique and challenging clinical scenario of an adult patient who presented with multiple intestinal intussusceptions coinciding with inflammatory gallbladder polyps, an association scarcely documented in medical literature. Adding further complexity to the scenario, these multiple intussusceptions, diagnosed on CT scan, self-resolved till exploratory laparotomy was performed leaving chances for recurrences in the future. This case report may serve as a valuable resource for surgeons regarding the concurrence of these medical conditions, underscoring the importance of considering wide aspects of differential diagnoses in patients with abdominal pain. This case report has been reported in line with SCARE 2023 criteria ( 16 ). Case presentation History A 41-year-old male married patient presented to the outpatient clinic with complaints of abdominal pain, and alternating episodes of diarrhea and constipation for the last 5 months. The abdominal pain was associated with a feeling of gaseous abdomen. The pain was gradual in onset, diffuse, and colicky in nature with no radiation or shifting. It was aggravated by food intake, with no significant relieving factors. The gas accumulation in the abdomen was associated with distention for about an hour following a meal. There were alternating episodes of diarrhea and constipation with the frequency of twice a week throughout the entire 5 months preceding his presentation. The patient had taken pain and diarrhea medications throughout this period but there was no significant relief of symptoms. He reported a marked unintentional weight loss of 15kg during this period, decreased appetite and melena for the last 2 months. There was no significant past medical and surgical history. However, regarding family history, the patient’s father died post-surgery for bowel obstruction. The patient was of low socioeconomic status and took tobacco snuff (Naswar) for the last 12 years. Physical Examination The patient was fully conscious. On inspection, he looked emaciated with pallor of mucus membranes on inspection. He had no clinical jaundice. The head and neck were unremarkable, and the chest was normal in shape, moved symmetrically with respiration, and had no scars. Breath sounds were normal on auscultation. . Upon inspection the abdomen was found to be normal scaphoid in shape, moved with respiration, had no scars and the umbilicus was of normal shape and centrally placed. Palpation revealed a soft, non-tender abdomen with no palpable mass. The percussion note was tympanic and bowel sounds were present upon auscultation. On digital rectal examination (DRE) no masses, ulcers, draining orifices, or swelling were observed. The anal tone was normal on palpation with no swelling, mass, blood stain, or stool stain. Provisional Diagnosis Based on the history and examination of the patient a provisional diagnosis of familial polyposis syndrome, celiac disease, or inflammatory bowel disease was made. Investigations Of all the investigations performed, the only significant finding was a low hemoglobin of 8.8 g/dl and raised lymphocytes up to 43.0% (Figure:1). Ultrasound Abdomen (USG) CECT Scan of the Abdomen and Pelvis (Triphasic) Investigation Finding Blood CP test Hemoglobin of 8.8 g/dl, lymphocytes up to 43.0% Ultrasound Abdomen Multiple echogenic foci adherent to the gallbladder wall CECT Scan of Abdomen & Pelvis Multiple gut intussusceptions (Particularly Prominent in 4 areas) Diagnosis A diagnosis of gallbladder polyps and multiple intussusceptions was made. Per-operative findings A laparoscopic cholecystectomy and exploratory laparotomy were performed. On laparoscopic cholecystectomy, a densely adherent gallbladder was observed and was successfully removed with minimal bleeding. The exploratory laparotomy was performed from the ileocecal valve and moved proximally all the way to the ligament of treitz. Though no intussusceptions were found, there were multiple abnormal constrictions throughout the ileum and jejunum which were suggestive of intussusceptions that had spontaneously healed, with possible recurrence in future. The patient received comprehensive counseling regarding his condition and the importance of regular follow up was emphasised. Discussion and Conclusions Intestinal intussusception is an invagination of the proximal part of the small intestine into the distal part along with its mesentery, leading to impaired peristaltic movements, obstruction, and vascular compromise. The exact mechanism of this condition remains unclear. However, some studies suggest that it occurs due to an underlying gut pathology or irritant that disturbs normal peristaltic activity, forming lead points for intussusceptum ( 17 , 18 ). After the formation of lead points, ingested food and subsequent peristalsis form a constricted area above the stimulus with relaxation below, thus telescoping the lead point through the distal part ( 19 , 20 ). Intussusceptions are classified into three major categories, namely; entero-enteric, ileocolic, and colocolic. Entero-enteric intussusception is bound to the small intestine, colocolic confined to the large intestine while in ileocolic, the ileum telescopes through the ileocecal valve ( 2 , 12 , 17 ). Multiple adult intussusceptions occur rarely but are more frequent in the small than in the large intestines. More than 90% of adult intussusceptions are caused by lead points due to underlying mural, intramural, or extramural pathology ( 11 , 19 ). Lead points in the small intestines are usually benign conditions, such as tumors, lymphoid hyperplasia, scleroderma, adhesions, cystic fibrosis, celiac disease, inflammatory bowel disease among others. Among adult intussusception cases, 16% of the cases are idiopathic with no underlying gastrointestinal pathology or lead point ( 21 ). Our case had a similar presentation, with no identifiable cause. However, inflammatory gallbladder polyps were a unique and rare concurrence with no previous case reported in the literature. In one case reported in literature, intestinal intussusception in a 38-year-old female was secondary to inflammatory fibroid polyps in the small intestine. Inflammatory fibroid polyps are rare, benign, tumor-like lesions occurring in any part of GIT, more commonly in the small bowel ( 22 ). In yet another one, a similar case of jejuno-jejunal intussusception in a 20-year-old female reported presented with intestinal obstruction and was secondary to an inflammatory fibroid polyp in small bowel. In both cases, inflammatory fibroid polyps in the small intestine served as lead points for the intussusceptions ( 23 ). Simultaneous occurrence of multiple intussusceptions is a rare condition, with the exact incidence unknown. Likewise, the multiple intussusceptions in the small bowel in our case had no significant lead point. However, some authors have reported cases of multiple intussusceptions which were associated with an underlying benign or malignant GIT pathology. In one, intussusceptions were observed at 2 points along the ileum and were caused by an ileus tube that had been inserted to treat paralytic ileus in 87 year old woman ( 24 ). However, in yet another one, multiple small intestinal intussusceptions were secondary to segmentary lipomatosis of the ileum ( 25 ). GIT malignancy may also serve as a significant lead point for the development of intussusception. In one rare case, jejuno-jejunal intussusception in a 14 year old boy was secondary to an adenocarcinomatous polyp, observed 70cm from the ligament of Trietz ( 26 ). Another report cited a rare concurrence of ileo-ileal intussusception secondary to malignant amelanotic melanoma that had metastasized into the small intestine. The treatment was surgical resection and anastomosis of the bowel ( 27 ). Adult interstitial intussusceptions are rarely primary or idiopathic. In our case, multiple intussusceptions, though not directly associated with bowel pathology, were secondary to gallbladder polyps, which may or may not serve as a lead point. However, a case of idiopathic intestinal intussusception in a 32-year-old male with no pathologic lead point, has been reported in literature ( 28 ). Another case of idiopathic adult intussusception reported was a 67-year-old woman who had a history of several abdominal procedures and irritable bowel syndrome ( 29 ). Children with intestinal intussusception present with a classical triad of abdominal pain, palpable tender abdominal mass, and bloody currant jelly stools. Adults rarely present with this triad but may present with acute abdominal obstruction, cramping pain, and vomiting, leading to a broad differential diagnosis ( 19 ). From the clinical presentation to radiological assessment, there are many diagnostic modalities that can lead to preoperative diagnosis. The evaluation begins with an X-ray of the abdomen that may reveal intestinal obstruction or perforation signs. However, it lacks specificity and sensitivity for diagnosing intestinal intussusception ( 30 – 32 ). Ultrasound (USG) of the abdomen has 100% sensitivity and specificity for diagnosing intestinal intussusception. Moreover, the USG abdomen has therapeutic significance in the non-operative reduction of intussusception via USG-guided fluoroscopic pneumatic or hydrostatic enema. Ultrasound has less accuracy in adults but might reveal some classic features of intussusception ( 31 , 33 ) In our case, USG revealed a well-distended gallbladder with multiple polyps, more marked in the region of the neck and body. Regarding intestines, USG revealed minimal bowel wall thickening measuring up to 0.39cm with intergut loop fluid present. No enlarged mesenteric lymph nodes were seen. The most accurate diagnostic modality is abdominal CECT which shows lead points, bowel obstruction, vascular compromise, and associated complications ( 34 ). The triphasic CECT scan abdomen revealed multiple (approximately four) intestinal intussusceptions with no definitive lead point. The telescoping of the small gut loop into the distal mildly dilated gut was noted at multiple points in the distal jejunum and ileum regions. One of the most widely accepted treatment modalities of adult intestinal intussusception includes resection of the involved bowel loop and establishing primary anastomosis ( 12 ). The treatment of intussusception depends on treating the underlying etiology. A 10-year retrospective cohort study revealed evidence of the beneficial effects of beginning with tumour resection or bowel loop resection with/without prior reduction in cases of intussusception that is secondary to benign or malignant tumor ( 35 ). Other authors argue that intestinal resection with immediate anastomosis is the treatment of choice for most patients despite the nature of the underlying etiology ( 36 ). In our case, all the intussusceptions spontaneously resolved without any surgical resection. During exploratory laparotomy, intussusception was evidenced by the presence of multiple constrictions in the distal jejunum and ileum regions. Declarations Ethical Approval and Consent to participate- No institutional approval was required for the case report but consent was obtained from the patient. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Availability of supporting data All supporting data is available in the manuscript. Competing interests All authors declare no competing interests. Funding No funding was received. Authors' contributions Haris Mumtaz Malik- Data collection, production of the first draft, reviewing and editing of the manuscript. Beenish Sabir- Data collection, production of the first draft, reviewing and editing of the manuscript. Doreen Macherera Mukona- Reviewing of drafts, language editing, technical editing, production of the final draft and corresponding author. Shafaq Saleem- Data collection, production of the first draft, reviewing and editing of the manuscript. Gulzeryam Muneer- Data collection, production of the first draft, reviewing and editing of the manuscript. Eeman Khalid Data collection, production of the first draft, reviewing and editing of the manuscript. Acknowledgements We acknowledge the patient who consented to the publication of this case report. References Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, Theodosopoulos T. Intussusception of the bowel in adults: a review. 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Adult\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eIntestinal intussusception is the inversion of a portion of the proximal part of the intestinal loop within the distal part of the loop (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The pathophysiology includes altered bowel peristalsis at the intraluminal lesion, which serves as a lead point for intussusception (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Intussusception is a rare, but potentially life-threatening disease more common in children than adults with an incidence of 1\u0026ndash;3 cases per 1,000,000 population each year (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Most patients present with non-specific symptoms such as generalized abdominal pain and vomiting, hence the diagnosis is often missed leading to complications such as intestinal obstruction and vascular compromise (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Half of these cases are diagnosed during exploratory laparotomy or any other surgical operations while some are diagnosed with some diagnostic modalities such as plain abdominal film, ultrasound, and abdominal CT scan (\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMore than 90% of intussusceptions in children are idiopathic while 70\u0026ndash;90% in adults are secondary to an underlying gut wall disease. Among these cases in adults, more than 65% are caused by benign or malignant neoplasms (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), with the remainder of cases being secondary to non-specific processes (15\u0026ndash;25%) and idiopathic causes (less than 10%) (\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn more than 90% of cases, intestinal intussusception occurs due to well-definable underlying gastrointestinal tract (GIT) pathology. These include malignancy, adenomas, lipomas, post-op adhesions, leiomyomas, Meckel\u0026rsquo;s diverticulum, lymphoid enlargement, celiac disease, cytomegalovirus (CMV) infection, or inflammatory fibroid polyps. Gallbladder polyps are non-motile mucosal elevations, protruding from the gallbladder mucosa into the lumen (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). These sessile pedunculated mucosal elevations are categorized as either pseudo- or true polyps. True polyps are usually adenomas of the gallbladder mucosa and may potentially be malignant. They can also be benign, including lipomas, fibromas, leiomyomas, or malignant, including lymphoma, and mesenchymal neoplasms, which are rarer than common adenomas. On the other hand, pseudopolyps are benign and include cholesterol foci, inflammatory polyps, or adenomyomatosis (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere is scanty literature on the concurrence of multiple intestinal intussusceptions with inflammatory gallbladder polyps. However, to our knowledge, there is no previous case of spontaneous healing of intestinal intussusceptions reported with surgical interventions being done in almost all the cases.\u003c/p\u003e \u003cp\u003eThis case report presents a unique and challenging clinical scenario of an adult patient who presented with multiple intestinal intussusceptions coinciding with inflammatory gallbladder polyps, an association scarcely documented in medical literature. Adding further complexity to the scenario, these multiple intussusceptions, diagnosed on CT scan, self-resolved till exploratory laparotomy was performed leaving chances for recurrences in the future. This case report may serve as a valuable resource for surgeons regarding the concurrence of these medical conditions, underscoring the importance of considering wide aspects of differential diagnoses in patients with abdominal pain. This case report has been reported in line with SCARE 2023 criteria (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eHistory\u003c/h2\u003e \u003cp\u003eA 41-year-old male married patient presented to the outpatient clinic with complaints of abdominal pain, and alternating episodes of diarrhea and constipation for the last 5 months. The abdominal pain was associated with a feeling of gaseous abdomen. The pain was gradual in onset, diffuse, and colicky in nature with no radiation or shifting. It was aggravated by food intake, with no significant relieving factors. The gas accumulation in the abdomen was associated with distention for about an hour following a meal. There were alternating episodes of diarrhea and constipation with the frequency of twice a week throughout the entire 5 months preceding his presentation. The patient had taken pain and diarrhea medications throughout this period but there was no significant relief of symptoms. He reported a marked unintentional weight loss of 15kg during this period, decreased appetite and melena for the last 2 months.\u003c/p\u003e \u003cp\u003eThere was no significant past medical and surgical history. However, regarding family history, the patient’s father died post-surgery for bowel obstruction. The patient was of low socioeconomic status and took tobacco snuff (Naswar) for the last 12 years.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePhysical Examination\u003c/h2\u003e \u003cp\u003eThe patient was fully conscious. On inspection, he looked emaciated with pallor of mucus membranes on inspection. He had no clinical jaundice. The head and neck were unremarkable, and the chest was normal in shape, moved symmetrically with respiration, and had no scars. Breath sounds were normal on auscultation. .\u003c/p\u003e \u003cp\u003eUpon inspection the abdomen was found to be normal scaphoid in shape, moved with respiration, had no scars and the umbilicus was of normal shape and centrally placed. Palpation revealed a soft, non-tender abdomen with no palpable mass. The percussion note was tympanic and bowel sounds were present upon auscultation. On digital rectal examination (DRE) no masses, ulcers, draining orifices, or swelling were observed. The anal tone was normal on palpation with no swelling, mass, blood stain, or stool stain.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eProvisional Diagnosis\u003c/h2\u003e \u003cp\u003eBased on the history and examination of the patient a provisional diagnosis of familial polyposis syndrome, celiac disease, or inflammatory bowel disease was made.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInvestigations\u003c/h3\u003e\n\u003cp\u003eOf all the investigations performed, the only significant finding was a low hemoglobin of 8.8 g/dl and raised lymphocytes up to 43.0% (Figure:1).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eUltrasound Abdomen (USG)\u003c/h2\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCECT Scan of the Abdomen and Pelvis (Triphasic)\u003c/h2\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e\u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInvestigation\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFinding\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood CP test\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHemoglobin of 8.8 g/dl, lymphocytes up to 43.0%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUltrasound Abdomen\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultiple echogenic foci adherent to the gallbladder wall\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCECT Scan of Abdomen \u0026amp; Pelvis\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMultiple gut intussusceptions (Particularly Prominent in 4 areas)\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDiagnosis\u003c/h2\u003e \u003cp\u003eA diagnosis of gallbladder polyps and multiple intussusceptions was made.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePer-operative findings\u003c/h3\u003e\n\u003cp\u003eA laparoscopic cholecystectomy and exploratory laparotomy were performed.\u003c/p\u003e \u003cp\u003eOn laparoscopic cholecystectomy, a densely adherent gallbladder was observed and was successfully removed with minimal bleeding. The exploratory laparotomy was performed from the ileocecal valve and moved proximally all the way to the ligament of treitz. Though no intussusceptions were found, there were multiple abnormal constrictions throughout the ileum and jejunum which were suggestive of intussusceptions that had spontaneously healed, with possible recurrence in future. The patient received comprehensive counseling regarding his condition and the importance of regular follow up was emphasised.\u003c/p\u003e "},{"header":"Discussion and Conclusions","content":"\u003cp\u003eIntestinal intussusception is an invagination of the proximal part of the small intestine into the distal part along with its mesentery, leading to impaired peristaltic movements, obstruction, and vascular compromise. The exact mechanism of this condition remains unclear. However, some studies suggest that it occurs due to an underlying gut pathology or irritant that disturbs normal peristaltic activity, forming lead points for intussusceptum (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). After the formation of lead points, ingested food and subsequent peristalsis form a constricted area above the stimulus with relaxation below, thus telescoping the lead point through the distal part (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Intussusceptions are classified into three major categories, namely; entero-enteric, ileocolic, and colocolic. Entero-enteric intussusception is bound to the small intestine, colocolic confined to the large intestine while in ileocolic, the ileum telescopes through the ileocecal valve (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eMultiple adult intussusceptions occur rarely but are more frequent in the small than in the large intestines. More than 90% of adult intussusceptions are caused by lead points due to underlying mural, intramural, or extramural pathology (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Lead points in the small intestines are usually benign conditions, such as tumors, lymphoid hyperplasia, scleroderma, adhesions, cystic fibrosis, celiac disease, inflammatory bowel disease among others. Among adult intussusception cases, 16% of the cases are idiopathic with no underlying gastrointestinal pathology or lead point (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Our case had a similar presentation, with no identifiable cause. However, inflammatory gallbladder polyps were a unique and rare concurrence with no previous case reported in the literature. In one case reported in literature, intestinal intussusception in a 38-year-old female was secondary to inflammatory fibroid polyps in the small intestine. Inflammatory fibroid polyps are rare, benign, tumor-like lesions occurring in any part of GIT, more commonly in the small bowel (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In yet another one, a similar case of jejuno-jejunal intussusception in a 20-year-old female reported presented with intestinal obstruction and was secondary to an inflammatory fibroid polyp in small bowel. In both cases, inflammatory fibroid polyps in the small intestine served as lead points for the intussusceptions (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Simultaneous occurrence of multiple intussusceptions is a rare condition, with the exact incidence unknown. Likewise, the multiple intussusceptions in the small bowel in our case had no significant lead point.\u003c/p\u003e\u003cp\u003eHowever, some authors have reported cases of multiple intussusceptions which were associated with an underlying benign or malignant GIT pathology. In one, intussusceptions were observed at 2 points along the ileum and were caused by an ileus tube that had been inserted to treat paralytic ileus in 87 year old woman (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). However, in yet another one, multiple small intestinal intussusceptions were secondary to segmentary lipomatosis of the ileum (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). GIT malignancy may also serve as a significant lead point for the development of intussusception. In one rare case, jejuno-jejunal intussusception in a 14 year old boy was secondary to an adenocarcinomatous polyp, observed 70cm from the ligament of Trietz (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Another report cited a rare concurrence of ileo-ileal intussusception secondary to malignant amelanotic melanoma that had metastasized into the small intestine. The treatment was surgical resection and anastomosis of the bowel (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Adult interstitial intussusceptions are rarely primary or idiopathic. In our case, multiple intussusceptions, though not directly associated with bowel pathology, were secondary to gallbladder polyps, which may or may not serve as a lead point. However, a case of idiopathic intestinal intussusception in a 32-year-old male with no pathologic lead point, has been reported in literature (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Another case of idiopathic adult intussusception reported was a 67-year-old woman who had a history of several abdominal procedures and irritable bowel syndrome (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Children with intestinal intussusception present with a classical triad of abdominal pain, palpable tender abdominal mass, and bloody currant jelly stools. Adults rarely present with this triad but may present with acute abdominal obstruction, cramping pain, and vomiting, leading to a broad differential diagnosis (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFrom the clinical presentation to radiological assessment, there are many diagnostic modalities that can lead to preoperative diagnosis. The evaluation begins with an X-ray of the abdomen that may reveal intestinal obstruction or perforation signs. However, it lacks specificity and sensitivity for diagnosing intestinal intussusception (\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e–\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Ultrasound (USG) of the abdomen has 100% sensitivity and specificity for diagnosing intestinal intussusception. Moreover, the USG abdomen has therapeutic significance in the non-operative reduction of intussusception via USG-guided fluoroscopic pneumatic or hydrostatic enema. Ultrasound has less accuracy in adults but might reveal some classic features of intussusception (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) In our case, USG revealed a well-distended gallbladder with multiple polyps, more marked in the region of the neck and body. Regarding intestines, USG revealed minimal bowel wall thickening measuring up to 0.39cm with intergut loop fluid present. No enlarged mesenteric lymph nodes were seen.\u003c/p\u003e\u003cp\u003eThe most accurate diagnostic modality is abdominal CECT which shows lead points, bowel obstruction, vascular compromise, and associated complications (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The triphasic CECT scan abdomen revealed multiple (approximately four) intestinal intussusceptions with no definitive lead point. The telescoping of the small gut loop into the distal mildly dilated gut was noted at multiple points in the distal jejunum and ileum regions.\u003c/p\u003e\u003cp\u003eOne of the most widely accepted treatment modalities of adult intestinal intussusception includes resection of the involved bowel loop and establishing primary anastomosis (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The treatment of intussusception depends on treating the underlying etiology. A 10-year retrospective cohort study revealed evidence of the beneficial effects of beginning with tumour resection or bowel loop resection with/without prior reduction in cases of intussusception that is secondary to benign or malignant tumor (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Other authors argue that intestinal resection with immediate anastomosis is the treatment of choice for most patients despite the nature of the underlying etiology (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). In our case, all the intussusceptions spontaneously resolved without any surgical resection. During exploratory laparotomy, intussusception was evidenced by the presence of multiple constrictions in the distal jejunum and ileum regions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical Approval and Consent to participate- No institutional approval was required for the case report but consent was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of supporting data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll supporting data is available in the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eHaris Mumtaz Malik- Data collection, production of the first draft, reviewing and editing of the manuscript.\u003c/li\u003e\n \u003cli\u003eBeenish Sabir- Data collection, production of the first draft, reviewing and editing of the manuscript.\u003c/li\u003e\n \u003cli\u003eDoreen Macherera Mukona- Reviewing of drafts, language editing, technical editing, production of the final draft and corresponding author.\u003c/li\u003e\n \u003cli\u003eShafaq Saleem- Data collection, production of the first draft, reviewing and editing of the manuscript.\u003c/li\u003e\n \u003cli\u003eGulzeryam Muneer- Data collection, production of the first draft, reviewing and editing of the manuscript.\u003c/li\u003e\n \u003cli\u003eEeman Khalid\u0026nbsp;Data collection, production of the first draft, reviewing and editing of the manuscript.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the patient who consented to the publication of this case report.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMarinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, Theodosopoulos T. Intussusception of the bowel in adults: a review. World journal of gastroenterology: WJG. 2009;15(4):407.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAhn JH, Choi SC, Lee KJ, Jung YS. A clinical overview of a retrospective study about adult intussusceptions: focusing on discrepancies among previous studies. Digestive diseases and sciences. 2009;54:2643\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePotts J, Al Samaraee A, El-Hakeem A. Small bowel intussusception in adults. The Annals of The Royal College of Surgeons of England. 2014;96(1):11-4.\u003cdiv class=\"InlineMediaObject\"\u003e\u003c/div\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManouras A, Lagoudianakis EE, Dardamanis D, Tsekouras DK, Markogiannakis H, Genetzakis M, Pararas N, Papadima A, Triantafillou C, Katergiannakis V. Lipoma induced jejunojejunal intussusception. World journal of gastroenterology: WJG. 2007;13(26):3641.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYalamarthi S, Smith RC. Adult intussusception: case reports and review of literature. Postgraduate Medical Journal. 2005;81(953):174\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLianos G, Xeropotamos N, Bali C, Baltogiannis G, Ignatiadou E. Adult bowel intussusception: presentation, location, etiology, diagnosis and treatment. Il Giornale di chirurgia. 2013;34(9\u0026ndash;10):280.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAydin N, Roth A, Misra S. Surgical versus conservative management of adult intussusception: Case series and review. International journal of surgery case reports. 2016;20:142\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEisen LK, Cunningham JD, Aufses Jr AH. Intussusception in adults: institutional review. 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Pediatr Radiol. 2006;36(11):1177\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaleato-Gonz\u0026aacute;lez S, Vilanova JC, Garc\u0026iacute;a-Figueiras R, Juez IB, Mart\u0026iacute;nez de Alegr\u0026iacute;a A. Intussusception in adults: what radiologists should know. Emerg Radiol. 2012;19(2):89\u0026ndash;101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOngom PA, Opio CK, Kijjambu SC. Presentation, aetiology and treatment of adult intussusception in a tertiary Sub-Saharan hospital: a 10-year retrospective study. BMC Gastroenterol. 2014;14:86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTarchouli M, Ait Ali A. Adult Intussusception: An Uncommon Condition and Challenging Management. Visc Med. 2021;37(2):120\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"intussusception, gall bladder polyps, laparoscopic surgery","lastPublishedDoi":"10.21203/rs.3.rs-4495026/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4495026/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eIntestinal intussusception is the inversion of a portion of the proximal part of intestinal loop into the distal part of the loop. It leads to intestinal obstruction and vascular compromise. This predicament is rare in adults and is usually associated with benign or malignant neoplasms but very rarely with Gallbladder polyps.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e We present a case of a 41 year old male, presenting with abdominal pain, alternating episodes of diarrhea and constipation and gaseous abdomen for the preceding 5 months. Patient had pallor of mucosa, no jaundice, normal scaphoid shaped and non-tender abdomen and unremarkable head and neck. On complete blood count (CBC) the patient had decreased hemoglobin and raised lymphocytes. Multiple gut intussusceptions were observed in 4 areas and multiple echogenic foci were also observed in the gallbladder. Laparoscopic cholecystectomy showed a densely adherent gallbladder. On exploratory laparotomy no intussusceptions were seen at the indicated areas but rather abnormal constrictions of the gut which indicated past intussusceptions, suspected to have spontaneously healed without intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eIntestinal Intussusceptions rarely occur in adults and are almost always accompanied by benign or malignant neoplasms. They rarely with illnesses such as gallbladder polyps. However, possibilities remain so these should not be ruled out without proper investigations. Proper follow up should therefore, be done owing to the possibility of recurrence.\u003c/p\u003e","manuscriptTitle":"A Unique Case of Self-Resolving Multiple Intestinal Intussusceptions Concurrent with Inflammatory Gallbladder Polyps in an Adult","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-01 19:00:01","doi":"10.21203/rs.3.rs-4495026/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4a8b22d7-18f3-4f5b-a6a0-93eed8223137","owner":[],"postedDate":"July 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-29T03:39:36+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-01 19:00:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4495026","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4495026","identity":"rs-4495026","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}