David B. Chessin, Chief Resident in General Surgery, Department of Surgery, The Mount Sinai Medical Center, New York, NY; David R. Stern, Resident in General Surgery, Department of Surgery, The Mount Sinai Medical Center, New York, NY; Tomas M. Heimann, Professor of Surgery, Department of Surgery, Bronx Veterans Affairs Medical Center, Bronx, NY
David B. Chessin, MD
Chief Resident in
Department of Surgery
The Mount Sinai
New York, NY
David R. Stern, MD
Resident in General
Department of Surgery
The Mount Sinai
New York, NY
Tomas M. Heimann,MD
Professor of Surgery
Department of Surgery
Bronx Veterans Affairs
Intussusception through an ileostomy is uncommon in adults and must be treated promptly to avoid further complications. The authors report a rare case of small bowel obstruction and necrosis caused by intussusception through a loop ileostomy in a male patient. They also review the literature regarding this entity and discuss other published reports.
Turnbull and colleagues first described loop ileostomy in 1971, and it has since become an increasingly popular procedure in colorectal surgery.1 Loop ileostomy has been used for fecal diversion to treat a wide range of conditions, including inflammatory bowel disease, trauma, radiation proctitis, and various other benign and malignant conditions of the colon, rectum, and pelvic organs.2 The main advantage of a loop ileostomy for fecal diversion is the relative ease with which it can be constructed and reversed; however, postoperative complications are reported to range from 5% to 100%.2 Common complications include prolapse, parastomal herniation, retraction, and obstruction. We report a case of small bowel obstruction and necrosis caused by intussusception through a loop ileostomy, a complication that is rarely reported.
A 49-year-old man with a medical history of human immunodeficiency virus, hepatitis C, and Child's A cirrhosis was admitted to the hospital for dysuria and pneumaturia. On physical examination, he appeared chronically ill and debilitated. An abdominal examination revealed a soft, nontender, nondistended abdomen with no scars or masses on palpation. A computed tomography scan of his abdomen and pelvis showed air in the bladder with adjacent sigmoid diverticulitis and a colovesical fistula.
As part of the patient's diagnostic workup, he underwent cystoscopy, which revealed an inflammatory patch at the dome of the bladder with a central ulcer that expressed a small amount of purulent material. Biopsies of this site found acute and chronic inflammatory tissue with focal urothelial hyperplasia. After the cystoscopy, the patient developed fecaluria. Flexible sigmoidoscopy revealed friable, ulcerated, nodular mucosa, approximately 15 cm to 20 cm from the anal verge. A biopsy of the mucosa revealed inflammatory exudate consistent with diverticulitis.
A diagnosis of colovesical fistula was made, and the patient was taken to the operating room for possible sigmoid resection. Intraoperatively, the distal small bowel, rectum, sigmoid colon, and bladder densely adhered to each other and formed a large inflammatory pelvic mass. The patient was treated with a diverting loop ileostomy proximal to the mass. He recovered well from this procedure and his urinary symptoms resolved. He was discharged from the hospital on postoperative day 15, afebrile, tolerating a regular diet, and with excellent ileostomy function.
The patient did well initially, but presented to the emergency department 16 weeks later reporting a 1-day history of prolapse of his ileostomy and passage of only a small amount of bloody fluid into the stoma bag. He was afebrile and had normal vital signs. On abdominal examination, significant prolapse of his ileostomy was confirmed. Although the prolapsed segment was edematous and dusky with some areas of necrosis, there was a 1-cm rim of normal-appearing mucosa by the skin (Figure 1). His abdomen was distended but soft and nontender on palpation. The patient's white blood cell count and electrolytes were normal. An obstructive series demonstrated dilated loops of small bowel with air-fluid levels consistent with a partial small bowel obstruction.
The patient was resuscitated and taken to the operating room for resection of the necrotic small bowel at the ileostomy site. A circular incision was made around the ileostomy, which was then mobilized. It was noted that 4 cm to 5 cm of ileum had intussuscepted through the proximal limb of the loop ileostomy and that this intussusceptum had become strangulated (Figure 2). The mesentery of the intussuscepted segment was divided, and the proximal and distal ends of the compromised bowel were transected using a linear cutting stapler. The proximal limb of ileum was used to create a new ileostomy through the same defect in the fascia and skin (Figure 3). The closed distal limb of viable ileum was placed in the subcutaneous tissue. Pathologic examination of the resected ileum revealed marked edema, congestion, and acute inflammation with areas of superficial necrosis (Figure 4). The patient recovered well and was discharged from the hospital on postoperative day 4, afebrile, tolerating a regular diet, and with excellent ileostomy function.
Intussusception through an ileostomy is extremely rare. A review of the literature from 1950 through 2005 revealed only three case reports.3-5?Interestingly, all of these cases occurred in pregnant women. To our knowledge, this case is the first report of intussusception through an ileostomy in a nongravid patient.
The first case report of intussusception through an ileostomy was published in 1959 and involved a 32-year-old woman who had an ileostomy to treat her ulcerative colitis 10 years before becoming pregnant.3 In month 6 of her pregnancy, she presented to the hospital with intussusception of the terminal ileum through the ileostomy. She was treated with a revision of the ileostomy. The authors did not comment on the viability of the bowel involved in the intussusception. The second case was published in 1992 and involved a 31-year-old woman who had an ileostomy for 8 years after total colectomy for ulcerative colitis.4 She was 21 weeks pregnant with twins and presented to the hospital with a prolapse of her stoma and colicky abdominal pain.4 Attempts at reduction were unsuccessful, and examination with the patient under anesthesia showed proximal ileum intussuscepting through the stoma. Slight congestion of the ileum was noted, and the intussusception required laparotomy for reduction. The third case was reported in 2005 and involved a 32-year-old woman with a long-standing history of Crohn's disease, multiple operations, and a left-sided ileostomy.5 She was 14 weeks pregnant and presented to the hospital reporting abdominal pain and vomiting.5?Physical examination revealed a prolapsed ileostomy that was congested and purple. The prolapse was not reducible, and intussusception of the bowel was discovered at laparotomy. It was reduced and the bowel was determined to be viable.
Although there were no other reported cases of an intussusception through an ileostomy, there was one report of an irreducible prolapsed colostomy secondary to a colocolonic intussusception in a 58-year-old man.6 A defunctioning colostomy was created in this patient 3 months before his presentation to the hospital for symptomatic relief from a recurrent sigmoid carcinoma. He presented with a prolapsed proximal limb of the colostomy that was reducible and managed conservatively. Two months later, he returned to the hospital reporting pain, and the colostomy had again prolapsed and was edematous and irreducible. The patient was taken to the operating room for revision of the colostomy. During the operation, the terminal ileum and cecum were discovered to have intussuscepted into the prolapsed colon. The cecum and prolapsed colon were resected and an end ileostomy was created.
Pregnancy is a common denominator of the reported cases of intussusception through an ileostomy. We hypothesize that increased intra-abdominal pressure during pregnancy may be an etiologic factor. Our patient was male and did not have increased intra-abdominal pressure; however, one similarity between our case and the other reported cases is the lack of an identifiable lead point as an underlying etiology for the intussusception.
While idiopathic intussusception is common in the pediatric population, it is rare in adults. Adult intussusception is associated with such pathologies as benign and malignant tumors, inflammatory lesions, and Meckel's diverticulum in up to 90% of cases.7 The Mayo Clinic reported a series of intussusception of the small and large bowel in which 86% of cases had a distinct pathology as the lead point.8 Furthermore, 46% of the lesions that served as lead points proved to be malignant.8?To our knowledge, this is the first description of a loop ileostomy as a predisposing factor for intussusception of the small intestine in an adult.
Intussusception through an ileostomy is rare, and must be treated promptly because it may result in bowel obstruction and necrosis. The diagnosis should be considered in patients with a prolapsed stoma, particularly those with a history or physical examination that suggests increased intra-abdominal pressure.
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