crohn s disease is a chronic granulomatous inflammatory disease that may involve any part of the alimentary tract , although the ileum is the most frequent location .
the presenting symptoms are variable and include abdominal pain , growth failure , and , less commonly , diarrhea . in the early stages , crohn s disease causes small erosions on the inner surface of the bowel ( aphthous ulcers ) . with time , the erosions become deeper and larger , causing scarring and stiffness of the bowel .
histologically , the active mucosal lesion shows a mixed infiltrate of lymphocytes , plasma cells , and neutrophils .
non - necrotizing granulomas are found in about 50% of resection specimens and may be located in any portion of the bowel wall .
crohn s disease was shown to be a predisposing factor for ileoileal intussusception ( 1 ) .
intussusception occurs when a proximal segment of bowel telescopes into an adjacent distal segment . unlike in children
we describe an unusual case of acute intestinal obstruction due to ileoileal intussusception as an initial manifestation of crohn s disease .
we speculate that intussusception was secondary to inflammatory edema and spasm , which led to impaired contraction of the bowel and allowed unbalanced peristaltic forces to rotate the intestinal wall inwards and initiate the invagination .
hence , crohn s disease should be taken into consideration in young patients with intestinal intussusception if no other cause is found .
a 20-year - old patient presented to emergency with complaints of central abdominal pain , vomitting , and bloody stool for the previous 2 days .
the abdomen was distended and examination revealed mild central abdominal tenderness with diminished bowel sounds .
routine investigations showed a raised white cell count of 21,200/mm , and a mild metabolic acidosis ( ph of 7.34 , serum level of bicarbonate of 18.12
an abdominal x - ray showed grossly distended loops of small intestine with absent colonic shadows , suggestive of mid - bowel obstruction ( figure 1 ) .
conservative treatment with nasogastric tube and endovenous fluids was initially instaured for at least 36 hours but ultrasound was later considered because there was no improvement .
ultrasonography showed a moderate amount of free fluid in the peritoneal cavity with distended bowel loops and enlarged lymph nodes in the mesentery .
contrast enhanced ct - scan ( figure 2 ) revealed a hypodense mass lesion in the pelvis , representing a thickened segment of bowel ( enteroenteric intussusception ) .
laparotomy revealed a moderate amount of serous free fluid , grossly distended proximal small bowel loops , and distal ileum intussusception .
enlarged lymph nodes were noted at the site of the intussusception . the intussusceptum segment ( 60 cm - long ileum )
finally , a 70 cm - long resection with side to side isoperistaltic anastomosis was carried out .
postoperative period was uneventful for the patient and he was discharged on the fifth day after surgery .
gross examination of the specimen showed extensive ( 60 cm - long ) bowel infarction . the rest of the bowel ( 10 cm - long ) was hemorrhagic and presented small longitudinal ulcerations with irregular borders in the mucosa ( figure 3 ) .
transmural inflammation , deep ulcerations , and non - necrotizing epithelioid cell granuloma ( sarcoid like - granulomas ) were demonstrated ( figure 4 ) .
a final diagnosis of inflammatory crohn s disease affecting the ileum was made . at 6 months
follow up , the patient was doing well and was receiving mesalazine 2 g orally for the treatment of crohn s disease .
one of the most common complications leading to surgery is chronic intestinal obstruction secondary to chronic inflammation with fibrous scar , which is rarely complete but is high grade ( 2 ) .
cases of intestinal obstruction secondary to small bowel intussusception by a segment of active crohn s ileitis have been rarely reported ( 1,3 ) .
symptoms are usually the same as for other types of intestinal obstruction . the classic triad of abdominal mass , pain , tenderness , and bloody stool is rarely found .
the aetiology of intussusception in the small bowel and the colon are different . in two thirds of cases
, intussusception arises in the small bowel and is more common in the proximal bowel due to increased peristaltic activity .
about 10% of intussusceptions in adults are primary and 8090% are secondary to an underlying pathology . of the latter , approximately 65%
are secondary to a benign lesion or malignant tumor , and 1520% of cases are due to processes other than tumor growth . with the widespread use of ct ,
the diagnosis is nowadays most often made by the radiologist since the ct features of intussusception are virtually pathognomonic ( 5,6 ) .
optimal management between reduction and primary resection in treatment of adult intussusception has caused some controversy .
some authors have established the principle of resection without reduction whenever possible based on a high incidence of underlying malignancy that could not be confirmed either preoperatively or intraoperatively ( 7 ) .
the problems against reduction include : risk of intraluminal seeding or venous embolization , possible perforation during manipulation , and subjection of the patient to increased risk of anastomotic leakage due to edematous bowel . in favor of reduction
nowadays , it is recommended to use a selective approach to resection that takes into consideration the site of intussusception that tends to influence the type of pathology ( 8) .
we advocate individualized treatment , depending on medical history and findings during intervention , as some cases of transient and acute intussusception have been observed on small bowel barium studies in patients with crohn s disease , adult coeliac disease , and many other benign conditions .
transient intussusception has been observed occasionally on small bowel barium studies in patients with crohn s and adult coeliac disease .
the leading point to the intussusception in crohn s disease is probably the dysrhythmic contractions secondary to the on - going inflammatory process of a thickened , inflamed segment of bowel wall ( 9 ) .
both patients underwent exploratory laparotomy , and no intraluminal mass was detected ( 10 ) .
the risk of developing short bowel syndrome in patients with crohn s disease is approximately 5% to 10% in reported series . as far as we know , this is the first case reported of small bowel intussusception as an initial manifestation of crohn s disease , for which long surgical resection was necessary and thus worsened the prognosis of the disease .
the incidence of short bowel syndrome ( sbs ) varies depending on the underlying disease process and its medical and surgical management . aggressive resectional therapy , surgical complications , and errors in initial diagnosis contribute to development of sbs in these patients ( 11 ) .
we conclude that small bowel intussusception might be the first manifestation of crohn s disease .
intussusception might be secondary to impaired contraction of the bowel associated with inflammation , edema and spasm .
management of small bowel intussusception in young patients should be individualized depending on the patient s medical history and intraoperative findings . in these cases ,
early exploration and reduction of the intussusception ( thus avoiding intestinal necrosis ) may prevent the onset of short bowel syndrome in the future .
we recommend urgent ct - scan in patients with a known history of crohn s disease and a sudden onset of abdominal pain to rule out intussusception and its potential complications . in these cases ,
 intussusception is usually considered a childhood condition , but it may also be present in adults , where it is more often associated with an underlying pathology . there is no agreement upon the correct treatment of adult intussusception , although surgical intervention is considered necessary . 
 resection without prior reduction has been the traditional treatment of choice due to the significant risk for malignancy found in most series . 
 we describe an unusual case of intestinal necrosis secondary to ileoileal intussusception caused by crohn s disease . 
 a long intestinal resection was necessary and the patient was discharged without major complications . 
 based on the details of this case , the authors emphasize the potential importance of considering individualized treatment of adult intussusception . the practical benefit for reduction of viable bowel in crohns patients is the preservation of bowel length . 
INTRODUCTION
CASE HISTORY
DISCUSSION
CONCLUSION