Sigmoid carcinoma with sigmoid-rectal intussusception presenting as rectal prolapse and large bowel obstruction in the ED

Case Discussion

Colo-rectal carcinoma is one of the commonest malignancy worldwide. Sigmoidcarcinoma presenting as large bowel obstruction due to the sigmoid-rectal intussusception with rectal prolapse in the ED is rare. Rectal prolapse refers to protrusion of the part of rectum through the anus. Rarely adenocarcinoma, lymphoma and metastasis and adenoma of the distal large bowel can act as lead point leading to the intussusception with resulting rectal prolapse. Adult intussusception poses a diagnostic dilemma to the clinician due to non- specific clinical presentation and clinical examination findings. Hence, radiology plays a vital role in diagnosis and the management of such cases. Plain abdominal x-rays are usually the first diagnostic tool, demonstrating signs of intestinal obstruction and providing information about probable site of obstruction. Ultrasonography (USG) may demonstrate the typical signs of intussusception like the 'donut sign', 'pseudokidney sign'. USG is often use in the pediatric population, However in adults, its utility is limited by air within the bowel lumen and greater depth between the skin and target anatomy. CT has emerged as a useful imaging modality for diagnosing intussusception in adults and is often performed for primary or secondary assessment of acute and subacute gastrointestinal symptoms of unclear origin. Similar to the USG,CT may also demonstrate target sign, wherein layers of the bowel are duplicated forming concentric rings when imaged at right angles to the lumen. As one images further along the intussusception the mesentery (fat and vessels) will form a crescent of tissue around the compressed inner most lumen, surrounded by the two layers of the outer enveloping bowel. Even further distally the lead point (if present) will be visualised. In addition, CT provides greater detail in illustrating local and regional anatomy, which can inform operative planning. An emergency laparotomy was performed in view of generalized guarding and rigidity of the abdomen, which revealed an intussusception of the distal sigmoid-rectum with growth, through the anal canal. Hartmann’s procedure was performed with resection of the sigmoid growth. The patient was discharged with healthy and functional transverse colostomy. The histopathology was reported as a moderately differentiated adenocarcinoma, infiltrating the submucosa and muscularis propria. The patient was referred to the oncology department for chemotherapy and had an uneventful course of treatment thereon.

Reference

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