P2.227: A Novel Case of Chronic Adolescent Intussusception Involving the Epiploic Appendix

Introduction: Intussusception is a condition in which part of the intestine slides and telescopes into an adjacent section, causing an obstruction. It most frequently occurs in children between 6 to 18 months old, but 3-4% of cases occur in patients greater than 10 years old. Intussusception often presents acutely with symptoms of intermittent abdominal pain, vomiting, and bloody stool. The etiology of intussusception in young children is often unknown.

Case Description: A 15-year-old healthy young man presents with 5 weeks of intermittent periumbilical pain with associated 10-pound weight loss after being punched in the stomach. Review of systems is negative for fever, vomiting, diarrhea, and bloody stools. Past medical history is notable for appendicitis at age 10 treated with antibiotics. On initial examination, the patient has normal vital signs with weight in the 90th percentile. Abdominal exam is soft with audible bowel sounds and no tenderness on palpation. Initial labs including complete blood count (CBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) are normal. Over the next 7 months, the patient’s abdominal pain progressively worsens with an additional weight loss of 50-pounds. He has multiple hospital visits and undergoes an extensive workup (see Table 1). Capsule endoscopy shows possible inflammation of the intestine. Magnetic resonance enterography (MRE) shows an intestinal loop invagination. He undergoes exploratory laparoscopy which identifies an ileoileal invagination secondary to the epiploic appendix; ileal resection and end-to-end anastomosis is performed. After the surgery, he makes a full recovery with complete resolution of his abdominal pain and eventually gains back the 60 pounds he lost.

Discussion: This case is unique given the patient’s age at presentation, chronicity of symptoms, and etiology of the intussusception. Intussusception classically presents with the sudden onset of intermittent abdominal pain with no associated weight loss. In contrast, our patient’s symptoms progressively worsened over 7 months and was associated with dramatic weight loss. Known causes of intussusception in adolescents include benign etiologies (e.g., Meckel’s diverticulum), malignant lesions (e.g., lymphoma), and rarely trauma. In our patient’s case, the etiology of his ileoileal intussusception was due to the epiploic appendix, which consists of small, fatty pouches that project from the intestinal surface. Inflammation of these appendages has been reported to cause bowel obstruction, volvulus, ileus, and intussusception. However, intussusception secondary to an uninflamed epiploic appendix has not been previously described in the adolescent population.

Conclusion: Intussusception commonly presents in infancy, but 3-4% of cases occur in patients greater than 10 years old. Intussusception classically presents with acute, intermittent abdominal pain, but it can also present atypically with more chronic symptoms. Thus, it is important to consider intussusception in the differential diagnosis when evaluating patients with chronic abdominal pain.