Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

Unique Presentation of Adult Ileocecal Intussusception Unveiling a Rare Culprit: A Carcinoid Tumor Christopher Zammit, OMS-III 1 , Margaret Munz, OMS-III 1 , Dr. Lindsay Tjiattas-Saleski, DO MBA FACOEP 1 , Joshua Bruce Knolhoff, MD 2

1 Edward Via College of Osteopathic Medicine - Carolinas Campus, Spartanburg, SC 2 St . Luke’s Hospital, Columbus NC

Abstract

Diagnostic Imaging

Discussion/Outcome

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Abstract: This case highlights a rare adult ileocecal intussusception provoked by a metastatic carcinoid tumor, emphasizing the significance of considering atypical causes and the need for swift diagnosis and surgical intervention. Neuroendocrine tumors in the small bowel are exceptionally rare, with an incidence of only 3.56 per 100,000 in the United States. Intussusception, accounting for just 5% of all bowel obstructions, is even rarer, comprising only about 1% of adult intestinal obstructions. While more common in pediatric cases, adult intussusception usually involves obstructive masses in over 90% of cases. ase Report: A 72-year-old male with a history of hypertension and hyperlipidemia presented with periumbilical abdominal pain. CT confirmed ileocecal intussusception, initially managed through observation but later necessitating surgical intervention. Pathological analysis revealed a metastatic carcinoid tumor originating in the ileum. This case underscores the importance of considering unusual etiologies in adult intussusception, the urgency of prompt intervention, and the potential for enhancing patient care through further research. Following surgical resection, the patient was recommended for imaging surveillance, with no additional clinical intervention needed.

Conclusions Diagnostic Complexity: The absence of typical carcinoid syndrome symptoms in this patient highlights the diagnostic challenges clinicians may face. Early Intervention: Timely identification and surgical management played a pivotal role in achieving a successful outcome. Clinical Vigilance: Healthcare providers should maintain a high index of suspicion in adult intussusception cases, especially when uncommon etiologies are suspected. Metastatic Surveillance: Regular monitoring for metastatic disease in carcinoid tumor patients, even in the absence of typical symptoms, is essential. Octreotide or somatostatin scans are also possible to monitor for metastasis. This patient was also recommended to receive a PET scan in 3-6 months. Future Research: Continued investigation and data collection in rare cases like this will contribute to improved understanding and management of such conditions in clinical practice. Rare Presentation: This case involves adult ileocecal intussusception associated with a metastatic carcinoid tumor in the ileum. The patient underwent an exploratory laparotomy, revealing a carcinoid tumor with lymph node involvement. The patient initiated a surveillance regimen, which includes abdominal/pelvic CT scans every 3-4 months during the first year and then annually for the next 10 years. The role of a chest CT scan was also considered for comprehensive staging, and a PET scan was scheduled for the first 3-4 month screening. Biomarkers were not discussed, as their use is recommended on a case-by-case basis according to the National Comprehensive Cancer Network (NCCN) guidelines. Uncommon Etiology: Adult intussusception is a seldom-seen condition, making up only 1% of adult intestinal obstructions. Benign or malignant tumors, with lipomas being the most common, are the typical culprits in adults. Carcinoid Tumors: These rare neuroendocrine neoplasms often lead to carcinoid syndrome, but in this case, the typical symptoms of carcinoid syndrome including flushing, diarrhea, wheezing, and weight loss were not present. Importance of Surveillance: Monitoring for metastasis through regular screening, as recommended by the NCCN, is crucial for carcinoid tumor patients. Options for surveillance include a CT of abdomen and pelvis every 3-4 months for the first year and every year for the next 10 years thereafter, as was recommended in the case of this patient. NCCN also recommends serial surveillance of biomarkers such as 5’ - HIAA every 3-6 months within the first year. Clinical Implications: This case underscores the significance of considering unusual etiologies in adult intussusception cases, emphasizing the need for timely diagnosis and surgical intervention.

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Figures 1-2: ED CT series prior to admission displaying small bowel obstruction, target sign, and crescent sign, suggestive of ileocecal intussusception. Figure 3: Supine Abdominal X-ray (Avg. 3.3 cm) revealing central, dilated gas-filled loops, confirming ongoing ileocolic intussusception, three days post admission.

Case Presentation

Patient Profile: A 72-year-old male with a history of hypertension and hyperlipidemia. Chief Complaint: Sudden onset periumbilical abdominal pain,

Intervention

Surgical Intervention: Despite conservative measures, ongoing obstruction on X-rays necessitated surgery. Procedure Details: Laparoscopic exploration followed by right hemicolectomy, including mesentery resection for lymph node assessment. Intraoperative Findings: Ileocecal intussusception observed without visible mass or malignancy signs. Pathological Evaluation: Excised specimen disclosed a grade 1 colon carcinoid tumor, with 3 out of 15 lymph nodes positive for metastasis.

accompanied by nausea and vomiting. No recent fever, chills, weight changes, or night sweats.

Family History: Positive for cancer of unknown origin in maternal family. Pertinent Surgical History: Inguinal hernia repair, hemorrhoidectomy, spinal fusion Physical Exam: The patient presented in mild distress with diffuse abdominal pain, but no peritoneal signs were evident. Vital Signs: HR 66; BP 115/72; Temp. 36.8 °C; RR 16; SpO2 99%; Wt 78.9 kg, Clinical Assessment: An emergency room CT scan confirmed intussusception, prompting NG tube insertion and subsequent admission for serial abdominal exams and surgical assessment. Imaging Confirmation: A CT with contrast scan confirmed ileocecal intussusception. Lab Work: Routine lab results were normal. Additional Symptoms: The patient reported loose stools and cramping with specific foods but did not exhibit diarrhea, flushing, or respiratory distress. Radiological Follow Up: Day three of admission revealed serial X-rays showing dilated gas-filled central enteric loops, raising suspicion of ongoing obstruction. Initial Treatment: Initial conservative management was initiated, including analgesia, antiemetics, NG tube placement for decompression and intravenous fluids. Evaluation

Pathology

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Acknowledgments

Figure 4: Mucosal Surface of Excised Ileal Tumor, Figure 5: High-Power Histological Examination of Ileal Tumor, Figure 6: Medium-Power View of Lymph Node Metastasis

We extend our gratitude to Dr. Salesksi and Dr. Knolhoff for their invaluable support and collaboration during this study.

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2024 Research Recognition Day