Intussusception of the small bowel in an adult associated with nephrotic syndrome.

Sir,

Here, we report our observations of a 39-year-old female who presented with progressive lower limb oedema over a 2-week period. She had no significant medical or family history. Physical examination revealed a right-sided pleural effusion and bilateral lower limb swelling. Laboratory investigations confirmed the clinical suspicion of nephrotic syndrome: albumin 14 g/L, creatinine 60 μmol/L, cholesterol 8.8 mmol/L, urinary protein–creatinine ratio (PCR) 997 mg/mmol. Complements were normal, and autoimmune serology was negative.

Percutaneous renal biopsy was performed and demonstrated features consistent with minimal change disease.

She was commenced on fluid and salt restriction and high-dose loop diuretics. She also received prednisolone 1 mg/kg orally [1]. Five days post-renal biopsy, she developed acute left-sided colicky abdominal pain. On physical examination, her abdomen was tender in the left iliac fossa with no signs of peritonism. The abdominal film was unremarkable. Abdominal ultrasound showed an iliocolic intussusception (Figure 1).

Fig. 1

Transverse section of intussuception. Bull’s-eye sign/target/crescent-in-doughnut. A. Intussicepiens. Concentric rings of alternating hypoechoic and hyperechoic layers. B. Returning limb of intussuceptum. C. Mesentery of intussuceptum. Central hyperechoic portion.

She remained clinically and biochemically nephrotic at this time. She entered the remission phase of nephrotic syndrome between Days 7 and 10 after the initiation of therapy which coincided with the complete resolution of her abdominal pain.

Gastrointestinal disturbances are frequently encountered in the course of nephrotic syndrome. The differential diagnosis considered included renal vein thrombosis, peptic ulcer disease and subacute bowel obstruction.

Fortuitously, at the time of ultrasonography, the patient developed an episode of colicky abdominal pain, and the intussusception could be demonstrated.

Ultrasonography is the diagnostic tool of choice to detect intussusception, although it can be operator dependent or limited by body habitus.

Intussusception causes ‘telescoping’ of the bowel due to a lead point in the bowel, which in this case is due to incoordinate gut motility and bowel wall oedema.

Intussusception is not infrequently described in the paediatric literature, but the usual cause in adults is secondary to a bowel tumour, which acts as a lead point for the invagination of the bowel [2]. Treatment of the underlying nephrotic syndrome resulted in resolution of the intussusception without the need for any intervention [3,4]. Infusions of albumin have also been described [5].

We conclude that nephrologists should consider intussusception in the differential diagnosis of abdominal pain in the setting of nephrotic syndrome as early recognition may improve prognosis.

Conflict of interest statement. None declared.