Intussusception through an ileostomy.

Dear Editor,

We would like to present a case of a 72-year-old male patient who presented to us with recent onset constipation and bleeding per rectum. On investigation he was diagnosed with a sigmoid malignancy for which we performed an anterior resection with a covering ileostomy. The pathology was a moderately differentiated adenocarcinoma stage IIIB (pT3N1). The postoperative recovery was uneventful. Four weeks later at a regular follow-up he was found to be doing well with no stoma related complications. That same night, after his meals, he developed acute abdominal pain and borborygmi and noticed his bowel protruding through the ileostomy site. On examination he was found to have a prolapsed ileostomy with mild abdominal distention and no stomal output [Figure 1]. A diagnosis of acute stomal prolapse with intestinal obstruction was made and he was started on supportive therapy. But failure to respond necessitated an exploratory laparotomy. Intra-operatively, we found an intussusception of proximal small bowel loop through the stoma for about 12-15 cm with the intussusceptum showing mucosal ulcerations and ischemic changes. The intussusception was reduced, but the bowel was ischemic needing resection. A search of the available literature revealed only six cases of intussusception through an ileostomy. The first three were young female patients with ileostomy done for inflammatory bowel disorders.[123] All three developed intussusception through ileostomy during their pregnancy, necessitating surgical intervention. The fourth was a 49-year-old immuno-compromised male patient with sigmoid diverticulitis and an inflammatory pelvic mass for which he underwent a diverting loop ileostomy.[4] This patient presented 16 weeks post-operatively with an intussusception through ileostomy which was treated with resection. The fifth was a 91-year-old female with an iatrogenic rectal perforation treated with a low rectal anastomosis and diverting loop ileostomy.[5] She presented with a stomal prolapse which was found to be a retrograde intussusception (through the distal limb) needing resection. The sixth patient was a 72-year-old male who had undergone a low anterior resection with covering loop ileostomy for a rectal cancer.[6] In the early postoperative period, he developed acute intestinal obstruction, vomiting, and was found to have a retrograde intussusception which was reduced surgically. In all these patients, there was no identifiable lead point causing the intussusception. In most of these patients there was a definite increased intra-abdominal pressure accounting for intussusception. But in the fourth and fifth cases and also our own, there was no such definite cause. Our patient had chronic obstructive pulmonary disease (COPD) but his cough was under control. Conservative measures were initially followed with a working diagnosis of prolapse, but later the patient had to be taken up for an emergency exploration and needed a resection. We would like to conclude that a high index of suspicion is essential when a patient with an ileostomy with no prior local complications presents with acute stomal prolapse and obstruction. This is especially true of patients having comorbidities causing increased intra-abdominal pressure.

Figure 1

Intussuscepted loop of bowel is seen here as a prolapse per stoma