Crohn’s Disease Presenting as Ileo-Ileal Intussusception: A Case Report

The authors present an unusual case of a 44 year old man who initially presented with urinary symptoms and underwent a CT scan of his abdomen, which showed an incidental finding of terminal ileal intussusception, which was investigated and found to be Crohn’s related. *Corresponding author: Mohammed Rashid, Department of General Surgery, West Suffolk Hospital, Suffolk, E-mail: amrd02@gmail.com Received March 22, 2012; Accepted April 19, 2012; Published April 20, 2012 Citation: Rouhani M, Rashid M, Sebastian B, Justin T (2012) Crohn’s Disease Presenting as Ileo-Ileal Intussusception: A Case Report. Surgery Curr Res 2:114. doi:10.4172/2161-1076.1000114 Copyright: © 2012 Rouhani M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


Introduction
Crohn's disease is a chronic inflammatory condition affecting the bowel [1], the incidence of which is ever increasing in Europe and the USA [2]. Diarrhoea, abdominal pain and weight loss are common presenting symptoms [3], but to date, there have been no cases in the literature of it being diagnosed after an incidental finding of a small bowel intussusception on a CT scan. Here, the authors present such as case.

Case Report
A 44 year old man was initially referred to the urology clinic in June 2011 with urinary symptoms including left sided loin pain and hesitancy. His past medical history included hypertension, asthma and varicose veins. He was a nonsmoker and only a social drinker. There was no family history of bowel problems. He had a renal ultrasound scan which showed a mild left sided hydronephrosis and was investigated further with a CT of his abdomen and pelvis. This showed a 13 mm ureteric calculus ( Figure 1) in the left proximal ureter causing mild hydronephrosis and also an ileo-ileal intussusception, a few small adjacent mesenteric nodes and mesenteric thickening (Figures 2, 3). He underwent a flexible ureteroscopy and lithotripsy in August 2011, after which all his symptoms resolved. In view of the intussusception he was reviewed in the surgical clinic, where it was noted that he was asymptomatic. Physical examination was unremarkable as were routine blood tests. He was investigated further with colonoscopy, which revealed erythema, granularity and aphthous ulcers within the colon and terminal ileum ( Figure 4). Biopsies were consistent with inflammatory bowel disease of Crohn's type, with no dysplasia. A barium follow through in November 2011 showed evidence of terminal ileal inflammation, with two areas of mild structuring, with resolution of the intussusception ( Figure 5).

Discussion
Crohn's disease is a chronic granulomatous inflammatory disease that may involve any part of the bowel, although the terminal ileum is the most frequently affected location. The presenting symptoms are variable and include abdominal pain, diarrhoea and weight loss. The incidence has been reported to vary worldwide, from 0.7 (Croatia) to 15.6 (Canada) new cases per 100,000 people per year [2]. Internationally accepted diagnostic criteria are defined by Lennard-Jones and include the presence of chronic inflammatory lesions in the bowel, a discontinuous disease distribution, transmural inflammation, fibrosis, lymphoid aggregates or aphthoid ulcers and retention of colonic mucin on biopsy in the presence of active inflammation [4].
Intussusception occurs when a proximal section of bowel invaginates into another adjacent section. It is more common in young children, where causes include any lesion in the lumen or disorganised peristalsis [5]. Only around 5% of all cases of intussusception occur in  adults [6]. Of these, 80-90% is secondary to an underlying pathology such as a tumour.
Crohn's disease presenting as an asymptomatic intussusception is rare in the literature. One such case in 2006, describes a patient who presented with an acute abdomen secondary to an intussusception from Crohn's disease but in this case, intestinal necrosis secondary to the ileoileal intussusception necessitated a small bowel resection, after which the patient made an uneventful recovery [7]. Also, transient intussusception has been reported before. A report from 1989 of two patients who were found to have a Crohn's related intussusception demonstrated on CT scan initially, found that later on, both intussusceptions had resolved on a repeat CT [8], without treatment.

Conclusion
Consideration should be given to Crohn's disease as a cause, in younger patients with intestinal intussusception.