Presentation, aetiology and treatment of adult intussusception in a tertiary Sub-Saharan hospital: a 10-year retrospective study.

BACKGROUND: Adult intussusception is a rare clinical condition worldwide. It contributes to less than 5% of all cases of intussusception. Few studies have been conducted in low-income countries compared to high-income countries; particularly Sub-Saharan Africa. Based on anecdotal evidence, the authors hypothesized that the condition is not as rare in a Sub-Saharan setting in comparison with western countries. We set out to conduct the first review study of adult intussusception in Uganda. METHODS: The medical records of 37 (out of a total of 62 cases) adolescent and adult patients with a postoperative diagnosis of intussusception at Mulago National Referral and Teaching Hospital, from January 2003 to December 2012, were analyzed. The clinical features, diagnosis, treatment and pathologic features of lesions for these patients were reviewed. Intraoperative findings were described with reference to: the site of the intussusception, and the triggering lesion (either idiopathic or with a lead point). RESULTS: The mean age was 33.6 years, with a range of 13 - 72 years. The male to female ratio was 1.85:1. The mean number of days for which symptoms had been present prior to presentation was 6.3 days, while the median was 4 days. All 37 patients presented with abdominal pain. Only 13 (35.1%) had the classical paediatric triad of abdominal pain, a palpable abdominal mass and bloody stool. Most of the remaining patients presented sub-acutely with non-specific symptoms. A lead point was present in 28 patients (75.7%). Of these, 24 (64.9%) cases involved tumours. Among the tumours, 54.2% were malignant. Treatment did not involve intussusception reduction in 14 patients (37.8%). Some form of operative surgery was conducted in 31 (83.8%) patients; mainly segmental bowel resections and hemi-colectomies. CONCLUSION: Adult intussusception is uncommon in the Uganda, though probably less so than in western countries. It presents sub-acutely or chronically and is often diagnosed at laparotomy. Lead points are the triggering lesion most times and are due mainly to tumours. The bulk of tumours are malignant. Most patients require surgical resection, with prior reduction done in selected cases.

Atypical gunshot injury to the right side of the face with the bullet lodged in the carotid sheath: a case report.

INTRODUCTION: Gunshot injuries of the head and neck from the AK-47 rifle (a common assault rifle, submachine gun type) are a significant contributor to morbidity and mortality among civilians in Sub-Saharan Africa. They may cause significant damage to the closely arranged structures in this region, and the bullet's trajectory can be very difficult to determine. We present an unusual case of gunshot injury with an atypical bullet entry wound, profound injury to the face, lodgment in the right carotid sheath, and 'wandering'; a first of its kind in East Africa. CASE PRESENTATION: A 27-year-old African-Ugandan woman of Nilotic ethnicity was referred to the Accident and Emergency Department of a tertiary hospital in Uganda, having sustained complex injuries due to an inadvertent AK-47 rifle gunshot injury. The gunshot injury was to the right side of her face with a large ragged entry wound and no exit wound. Prior basic wound care and radiological imaging showed a comminuted fracture of her mandible with lodgment of the bullet in her neck, anterior to her sixth and seventh cervical vertebrae. Standard debridement of her wound was done. A computed tomography scan showed an apparent cephalad shift ('wandering') of the bullet, leaving it lying partially anterior to her fifth cervical vertebra as well as within her carotid sheath. Other injuries were to her facial and trigeminal nerves, and her middle ear. The 'wandering' bullet was successfully removed surgically. It had caused no damage to any part of her neck structure. CONCLUSION: AK-47 rifle bullet injuries may present with uncharacteristically large entry wounds and cause complex structural injuries at the area of impact. The consequent trajectory is difficult to predict making regional examination and radiological investigations essential in management. Bullets may be retained, leaving no exit wound. Securing the airway, controlling hemorrhage and identifying other injuries are the first vital steps. This case illustrates all these interventions and the important decision to extract the entrapped bullet from the patient's neck because it had started to 'wander' and could have caused grave injury over time with further migration. Maxillofacial, plastic, trauma, general and military surgeons, otorhinolaryngologists and emergency physicians can gain from this experience because it calls for a multidisciplinary team approach.

Precipitous intussusception with anal protrusion and complete overt rectal prolapse presenting with intestinal obstruction and an associated rectal adenoma in a young man: a case report.

BACKGROUND: Intestinal obstruction secondary to intussusception, occurring simultaneously with complete rectal prolapse, is an unusual entity among young adults. When it occurs the intussusceptum may protrude per anus. Few cases are cited in literature; each with a unique clinical presentation. There is apparently no uniform trend in its clinical and pathological picture. CASE PRESENTATION: A 38-year-old, African-Ugandan man presented with sudden occurrence of rectal prolapse for one day. He had otherwise been in good health. Symptoms were precipitous. A clinical diagnosis of intussusception of the lower gut with rectal prolapse, and intestinal obstruction, was made. The intussusception was found to have a polyp as the 'lead point'. He was treated by manual reduction of the intussusception and the prolapse under general anesthesia. Histopathologic examination of the polyp showed it to be an adenoma. Definitive surgical treatment of the patient was not completed due to socioeconomic challenges. CONCLUSIONS: Rectal prolapse and intussusception are commonly childhood conditions. Rectal prolapse alone is commoner in the middle-aged and elderly; females in particular. The finding of this combined clinical entity in a young, adult male is therefore a unique condition with an unusual presentation. It is the first case of its kind reported in East Africa. It is also an example of an adenoma constituting a 'lead point' for an intussusception at the gastrointestinal tract's terminus. Even in the presence of a pre-existing adenoma, a relatively common lesion, other differential diagnoses acting as 'lead points' ought to be considered in perspective. This characteristic, along with other features described in this case, is useful knowledge for colorectal surgeons, general surgeons, gastrointestinal pathologists, and gastroenterologists given their involvement in the diagnosis and management of anorectal disease of peculiar presentation.

Metastatic colorectal carcinoma mimicking primary ovarian carcinoma presenting as 'giant' ovarian tumors in an individual with probable Lynch syndrome: a case report.

INTRODUCTION: Ovarian metastases occur in 3 to 8% of women with primary colon cancer. In the setting of a pre-existing colorectal carcinoma this would constitute a hereditary non-polyposis colorectal cancer, Lynch 2 syndrome, accounting for 5 to 10% of colon cancer cases. We unveil a case of 'giant' ovarian tumors mimicking primary ovarian cancer; ostensibly the first reported in East Africa. CASE PRESENTATION: A 58-year-old African woman was diagnosed with colorectal adenocarcinoma in June 2009. She had a right hemicolectomy with the tumor staged as regional cancer, following histopathological examination. Chemotherapy was administered both adjuvantly and 1 year later for what was thought to be a recurrence of tumor. Despite this, her general condition deteriorated. Following re-evaluation and an exploratory laparotomy she was found to have bilateral 'giant' ovarian tumors, with peritoneal seedlings and subcutaneous metastases (colonic in origin). A bilateral salpingo-oophorectomy was done, accompanied by histopathological analysis with institution of chemotherapy for ovarian cancer. Following immunohistochemistry tests and microsatellite instability analysis it was found that the ovarian tumors were secondaries from the colon. She was also identified as a Lynch syndrome case or a case of sporadic microsatellite instability, although with no suggestive family cancer history. The treatment regimen was changed to suit metastatic disease. CONCLUSIONS: The case presents a diagnostic and thus treatment conundrum. Two primary tumors (suspected Lynch syndrome) had been perceived yet there is actually only metastatic colorectal cancer. We also have a rare and unusual metastatic presentation: 'giant' bilateral ovarian tumors and subcutaneous nodules, concurrently. Further still, she is a case of probable Lynch syndrome, requiring genetic analysis for definitive classification and surveillance for hereditary non-polyposis colorectal cancer-associated cancers.Important inferences are drawn. Firstly, 'giant' ovarian tumors diagnosed as primary ovarian cancer may actually be colonic secondaries. Secondly, immunohistochemistry and microsatellite instability analysis tests ought to be part of the diagnostic package in colon cancer management, particularly for identifying tumor origin and the Lynch syndrome (a condition which has had little attention in resource-limited countries). Thirdly, multidisciplinary team collaboration is emphasized in colorectal cancer management.

Anal protrusion of an ileo-colic intussusception in an adult with persistent ascending and descending mesocolons: a case report.

BACKGROUND: Intussusception is one of the less common causes of intestinal obstruction among adults. It is usually covert (concealed) in its clinical presentation. The ileo-colic type with accompanying anal protrusion is extremely rare. The case at hand is that of both an ileo-colic intussusception with anal protrusion, in the presence of a persistence of both the ascending and descending mesocolons; a case possibly yet to be documented in literature. CASE PRESENTATION: A 32 year-old African-Ugandan woman presented with complaints of a mass protruding per anus for 2 weeks. It was reducible and associated with colicky abdominal pain, loose stools, and bloody-mucoid discharge per anus. She had previously had a one and a half month's history of abdominal pain; periodically continuous, while other times colicky in character. Examination and investigations revealed an intussusception with a partial intestinal obstruction. At laparotomy she was found to have an ileo-colic intussusception with a freely mobile colon throughout its length. There were persistent ascending and descending mesocolons, and absent hepatocolic and splenocolic ligaments. The intussusceptum was 'milked' but not completely reducible. A right hemicolectomy was done, with ileo-transverse colonic anastomosis. Histopathological examination revealed no preexisting pathologic lesion as a lead point. CONCLUSION: The persistence of the ascending and descending mesocolons (azygosis) best explains the anal protrusion of an ileo-colic intussusception with partial obstruction. In this case zygosis (normal retroperitoneal ascending and descending colonic positioning) failed embryologically. This experience is particularly beneficial to general surgeons, radiologists, gastroenterologists, colorectal surgeons and pathologists.

Efficacy of Gastrografin® Compared with Standard Conservative Treatment in Management of Adhesive Small Bowel Obstruction at Mulago National Referral Hospital.

INTRODUCTION: The treatment of adhesive small bowel obstruction is controversial, with both operative and non-operative management practiced in different centers worldwide. Non-operative management is increasingly getting popular, though operative rates still remain high. A study to compare the efficacy of an oral water-soluble medium (Gastrografin®) with standard conservative management, both non-operative methods, in the management of this condition was conducted in a tertiary Sub Saharan hospital. METHODS: An open randomised controlled clinical trial was conducted between September 2012 and March 2013 at Mulago National Referral and Teaching Hospital, Uganda. Fifty patients of both genders, with adhesive small bowel obstruction, in the hospital's emergency and general surgical wards were included. Randomisation was to Gastrografin® and standard conservative treatment groups. The primary outcomes were: the time interval between admission and relief of obstruction, the length of hospital stay, and the rates of operative surgery. RESULTS: All 50 recruited patients were followed up and analysed; 25 for each group. In the Gastrografin® group, 22 (88%) patients had relief of obstruction following the intervention, with 3 (12%) requiring surgery. The conservative treatment group had 16 (64%) patients relieved of obstruction conservatively, and 9 (36%) required surgery. The difference in operative rates between the two groups was not statistically significance (P = 0.67). Average time to relief of obstruction was shorter in the Gastrografin® group (72.52 hrs) compared to the conservative treatment group (117.75 hrs), a significant difference (P = 0.023). The average length of hospital stay was shorter in the Gastrografin® group (5.62 days) compared to the conservative treatment group (10.88 days), a significant difference (P = 0.04). CONCLUSION: The use of Gastrografin® in patients with adhesive small bowel obstruction helps in earlier resolution of obstruction and reduces the length of hospital stay compared with standard conservative management. Its role in reducing the rate of laparotomies remains inconclusive.

A 'giant' intraluminal lipoma presenting with intussusception in an adult: a case report.

INTRODUCTION: Intussusception is an uncommon cause of intestinal obstruction in adults. It usually presents with typical features of intestinal obstruction, and is associated with the presence of a 'lead point' for the invaginated portion. This 'lead point' is rarely an intraluminal, submucosal lipoma. CASE PRESENTATION: We describe the case of a 64-year-old African-Ugandan woman of Bantu ethnicity who presented with features of intestinal obstruction secondary to intussusception. She was treated operatively. A left colocolonic invagination was found with the interssusceptum having a giant polyp. A left hemicolectomy was performed. A histopathological examination revealed a polypoid, submucosal lipoma. CONCLUSIONS: In resource-rich countries, most cases of colonic intraluminal polyps are detected through colonoscopy during routine medical check-ups. With limited resources in our region, many tumors present as intestinal obstructions secondary to intussusception. Even then, most are associated with adenomas and malignancies. Rarely are polypoid, submucosal lipomas found. In our patient's case a polyp of 9.5cm at its widest dimension is of particular interest. A lesson to learn is that the differential diagnosis for intussusceptions in resource-poor countries should be broadened to include submucosal lipomas.