Journal of General Surgery

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Case Report

Non-Hodgkins Lymphoma of Small Intestine Causing Ileo-Colic Intussuception in Old Age Female: A Case Report

Dr Nandan M P, Dr Darshan A M

Correspondence Address :

Nandan M P, 2nd year
Postgraduate, Department of General Surgery
Shimoga Institute of Medical Sciences

Received on: December 28, 2022, Accepted on: January 25, 2023, Published on: January 30, 2023

Citation: Nandan M P (2023). Non-Hodgkins Lymphoma of Small Intestine Causing Ileo-Colic Intussuception in Old Age Female: A Case Report

Copyright: © 2023 Nandan M P. 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.

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Objective: Intussusceptions are rare but well-known causes of the small bowel obstruction in adults and an underlying cause is present in most cases. Lymphoma’s involvement of the ileum is one of the rare causes of intussusception. CT is a sensitive examination that diagnoses intussusceptions and provides an excellent pre-operative evaluation including possible extension and dissemination especially in intestinal lymphomas. The treatment is almost always surgical, and the pathological study is needed for diagnostic confirmation.

Methods: We present an unusual case of intestinal intussusception due to lymphoma of the terminal part of the ileum in a 63-year-old female. Computed tomography confirmed the diagnosis of intussusception and non-Hodgkin’s lymphoma was diagnosed by histological examination after surgical treatment. Results: Primary intestinal lymphomas differ from gastric lymphomas in clinical features, treatment, and prognosis. They are not well characterized and the standardized concepts for their clinical diagnosis and management are absent.

Conclusion: The aim of this rare observation is to shed light on NHL of the small bowel, its clinical and radiological diagnosis, and its treatment especially in forms revealed by intussusceptions in adults.

Keywords: Gastrointestinal lymphoma; Intussusception; Intestinal obstruction; non-Hodgkin’s lymphoma; Primary intestinal tumour



Intussusception is a process which occurs when a proximal segment of a bowel (intussusceptum) becomes telescoped into a distal segment (intussuscipiens) pulling the associated mesentery along with it [1]. From the various malignancies, lymphoma being the causative pathology is rare and for the most part discussed in isolated case reports. It is important to realize the potential severity of the underlying malignant process. We believe it is important to continue reporting these rare occurrences to increase our understanding of the disease process, presentation, and treatment option. NHL can arise as a primary disease of the lymph nodes or display as a malignancy at extra nodal sites. More than half the patients have some degree of extra nodal involvement at the time of their initial diagnosis. Based on these attributes, the malignancy may raid any organ system. NHL can affect the gastrointestinal tract, a phenomenon observed in 10% - 30% of all patients with the disease. However, bowel intussusception in the adult demographic is uncommon and accounts for only 5% of the total tally of intussusceptions observed [2].

Case Presentation
A 63-year-old female came with complaints of nonspecific pain in the right iliac fossa region in the past 1 week with no radiation and no aggravating factor. She was hemodynamically stable at the time of presentation. Physical examination revealed a thin, nontoxic appearing old female. Her abdomen was soft, nondistended, and tender in the right lower quadrant with localized guarding. She had no other significant physical examination findings. Initial laboratory results showed a normal white blood cell count. Computed tomography scan demonstrated Ileocolic intussusception with herniation of the terminal ileum into the caecum and ascending colon, showing diffuse asymmetrical wall thickening of terminal ileum with surrounding fat stranding and multiple enlarged mesenteric lymph nodes.

An ileo-caecal enbloc resection was performed with continuity restored by ileo-transverse side to side anastomosis (Figure 2). The specimen examination revealed a tumour of the terminal part of ileum with mesenteric adenopathy. No complications occurred and the patient was discharged on post operative day 5. Histological examination of the specimen showed sheets of large lymphoid cells with increased NC ratio, prominent 1-2 nucleoli and scant cytoplasm. Increased number of mitotic figures are seen. the submucosal lymphoid masses are covered by attenuated intestinal mucosa. The resected margins (ileum and colon) appear unremarkable. other tiny lymph nodes retrieved in the mesenteric fat shows reactive changes.

Intussusception is a rare disease in adults when compared with children; one case of adult intussusception for every 20 childhood ones [3]. In infants, intussusceptions are primitive in most cases [4]; however, in adults, an organic lesion is found in 80% of cases mostly in the benign and malignant disease in the ileum and the colon. These organic lesions are represented by the Gastrointestinal stromal tumours (GIST), lipomas, polyps, or adenopathy especially in the ileocecal localization [5]. Concerning the intestinal intussusceptions, it is defined by the telescoping and penetration of an intestinal segment in the downstream segment. Its evolutionary mode is usually sub-acute or chronic. Anatomically, in adults and regardless of the cause, the ileum is regarded as a preferential area of intussusceptions. The Colo-colic intussusceptions present only 27% of cases and the colorectal forms are rarer [6]. The hyperperistaltism result from the presence of a pedunculated or non-pedunculated mass acted on an intestinal segment. Hyperperistaltism would be triggered by neurovegetative reflexes and would be responsible for the formation of the width of intussusception which is the anatomic functional condition for the establishment of intussusceptions [7, 8].
Radiological diagnosis of intussusception especially the ileo-ceocal one caused by lymphoma can be suspected in ultra-sonography which can show a typical image of intussusception, but the computed tomography (CT) appearance of it is characteristic. It helps diagnose obstructive syndrome, its mechanism, the presence of the intussusception, its precise location and show its causes. It can also detect the organic cause in 71% of cases [9]. The most common finding in CT is a thickened segment of bowel with an eccentrically placed crescent-like fatty area, representing the intussusception and the intussuscepted mesentery. They appear either as a round target mass or as an oblong sausage shaped mass. Another common finding is a rim-shaped accumulation of contrast material in the periphery of the mass. In addition, air bubbles in the uppermost part of the intussusception can be observed in some cases [10]. The role of CT is more important in cases of suspected abdominal lymphoma and polyps. It can objective a thickening of the wall associated with digestive adenopathy in lymphoma or a tissue density in the event of polyp. Appropriate management of primary small bowel lymphoma is, therefore, still under discussion. One aspect of this discussion is that the surgical approach is necessary. Another aspect is that surgery is necessary but in combination with chemotherapy. According to few cases and to the absence of randomized trials in primary small bowel lymphoma, the optimal treatment strategy is not known [5]. However, the treatment of intussusceptions is always surgical, and the resection may be necessary to some extent [11]. If contraindications of laparoscopy are not present, laparoscopic resection can be performed safely and should be considered for diagnosis and treatment for intussusception in ileocecal lesions in adults. The most important rule in treatment is the avoidance of tumour emboli spread during manipulation [12]. If the primary small bowel lymphoma is diagnosed before or at laparotomy, surgical resection should be preferred to limit the risk of serious complications, such as perforation, bleeding, and obstruction. In early-stage patients, complete resection surgery is more advantageous in some reports [13-15].

In small case series, few retrospective studies of small bowel lymphomas have been reported. In recent years some progress has been achieved in the diagnosis and treatment of gastric lymphomas, but the primary small bowel lymphomas are not well characterized and there is little information on their clinical diagnosis and management. However, the treatment of ileal NHL revealed by intussusceptions in adults should always be surgical but preferably in combination with chemotherapy.


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