Intussusception from a Shelled Peanut Phytobezoar

Aela P Vely, MD, Harry L Anderson, III, MD, Luke O Pesonen, MD, Emily K Wilczak, Mary-Anne Purtill, MD, Theodore John, MD, Andrew T Catanzaro, MD, Stevany L Peters, MD. St. Joseph Mercy Ann Arbor

Although common in children, intussusception in adults is rare. It accounts for approximately 5% of the total incidence of intussusception and less than 5% of cases of intestinal obstruction. In adults, approximately 90% of cases of intussusception are associated with a pathologic lesion, which typically functions as the lead point for the intussusceptum.

Our case is a 37 year old male, who was otherwise healthy with no prior abdominal operations, who presented with less than 24 hours of right lower quadrant pain which was constant with colicky patterns. Eight hours prior to onset of his pain, he reported eating 2 small bags of salted, shelled peanuts, in which he ate the entire peanut – shell and all. His pain was not associated with nausea, vomiting, abdominal distention or diarrhea. He had evidence of complete obstruction, with no flatus or bowel movements since the onset of pain. He was afebrile, and physical examination revealed localized right lower quadrant pain but no evidence of peritonitis. Laboratory evaluation demonstrated a leukocytosis of 12,100 WBC/mm3. Computed tomography (CT) scanning with oral contrast revealed evidence of intussusception of the distal ileum into the cecum (arrow). Given his immediate dietary history of shelled peanut ingestion prior to development of his symptoms, he was admitted to the hospital with intravenous hydration, and nothing per mouth. The following morning, his exam improved significantly. A repeat abdominal x-ray in the morning showed migration of the oral contrast into the transverse colon. Colonoscopy performed the next day showed no masses and a normal colon, with localized inflammation near the ileocecal valve. The colonoscope was advanced beyond the ileocecal valve into the terminal ileum, with no other pathologic findings. Biopsy of the ileocecal valve area showed only inflammation.

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Cases of intussusception not associated with a pathologic lesion are uncommon. Azar and Berger (1997) reported 58 adult patients from 1964 to 1993 who underwent an operation, and were given a postoperative diagnosis of intussusception. In that series, 93% were found to be associated with a pathologic lesion, with the remaining cases (7%) due to idiopathic intussusception. A majority of the cases (44 out of 58) were enteric intussusception, and 48% of the lesions were malignant. For the cases of colonic intussusception (14 out of 58), a similar number (43%) of these lesions were malignant. The management of intussusception in adults is primarily surgical, given the high association of malignant pathology. A PubMed search of intussusception due to bezoar revealed only one case report (Calero et al., 2014), and in that report, the patient underwent small bowel resection, with the finding of intussusception of the mid-jejunum due to an intestinal bezoar. In our case report, the patient gave a clear history of antecedent ingestion of the entirety of peanuts within the shell, for which the CT scan was diagnostic for the intussusception and the accompanying phytobezoar. Employing subsequent colonoscopy with examination of the terminal ileum confirmed absence of other pathology.

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