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Description
A 64-year-old man presented to hospital with collapse on a 2-month history of loose stool progressing to watery diarrhoea 2–3 times/day with unintentional weight loss of 30% of his body mass over 3 months. He had a history of treated lung sarcoidosis, epilepsy and bipolar syndrome. Physical examination revealed a cachectic patient with bipedal oedema but no organomegaly, and no abdominal mass or lymphadenopathy. Initial blood tests demonstrated an acute kidney injury, coagulopathy and hypoalbuminaemia. He had haemoglobin of 14.9 g/dL, haematocrit 0.42, serum folate 3.6 mmol/L and ferritin of 298 μg/L. A CT of the abdomen showed three separate points of intussusception within the ileum but with no evidence of proximal obstruction (figures 1⇓–3). His blood tests showed tissue transglutamase IgA >200 and positive endomysial IgA antibody. A subsequent duodenal biopsy confirmed the diagnosis of coeliac disease (Marsh classification 3c). He was commenced on a gluten-free diet and his symptoms resolved.
Axial plane showing a point of intussusception as a target lesion to the left of the image.
Coronal plane showing the intussusception as a pouch within a pouch to the bottom left of the image.
Sagittal plane showing another pouch within a pouch point of intussusception in the middle of the image.
Intussusception in adults is rare and accounts for only 5% of all cases. However, of these, over 90% cases are secondary to an underlying pathological process, unlike in children where the majority are primary, benign cases with no underlying anatomical cause.1 The association between intussusception and coeliac disease was first described in 1978. The clinical presentation is variable, often non-specific, and can be the initial presentation of coeliac disease, as in our case. Studies suggest these patients have more severe disease at diagnosis.2 Symptoms usually resolve on adherence to a gluten-free diet and surgical intervention is rarely needed.
Learning points
Adult intussusception is rare but, when it occurs, it should be investigated as there is usually an underlying cause.
The differential diagnosis includes small bowel and colorectal malignancy, polyps, Meckel's diverticulum and coeliac disease.
Coeliac disease should be considered, as it is a common and treatable condition, and avoids the need for surgical intervention.
Acknowledgments
The authors would like to acknowledge the Radiology Department at the Royal London Hospital for providing the images.
Footnotes
Contributors This article was written by CS and CC with editing contributions from Professor WD and GP.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.