INTRODUCTION

Acute intussusception is a rare condition in adults, accounting for 1 to 2% of intestinal obstructions [1]. Prolapse of the intussusception loop through the anus is a rare complication, even in infants [2]. However, in coloanal varieties, the intussusception may protrude through the anus, where a rectal examination can differentiate it from rectal prolapse. Colorectal intussusception protruding through the anus in adults is unusual. A few cases have been reported in the global literature, most of which were secondary to a tumor, particularly a lipoma, carcinoma, or villous adenoma [3]. It often poses a differential diagnosis problem with a large polyp or rectal prolapse [4]. Treatment is always surgical in adults and often does not allow for reduction by hyperpressure under radiological control [5]. This study reports the observation of two cases of colo-colic intussusception prolapsed through the anus in adults, with their diagnostic and therapeutic difficulties.

OBSERVATIONS

Observation 1: Ms. X... Lucie, aged 44, was transferred from the Gynecology-Obstetrics department on 11/11/2019 for diffuse abdominal pain that had been developing for 4 days, accompanied by an abdominal mass and swelling around the anal margin. She had no specific medical history. She was in her fourth trimester, fourth pregnancy. On examination, her general condition was good, her blood pressure was 120/80 mmHg, and her pulse was 88 beats per minute. The patient did not have a fever. The abdomen was asymmetrical, flat, and on palpation, diffuse pain was noted without abdominal guarding. A firm mass was palpated in the left iliac fossa. At the anal margin, there was a dark red tumor prolapsed into the anus, approximately 15 cm in size, which was oozing bloody mucus. Attempts to reduce the mass were unsuccessful.

Figure 1 : view of a total intussusception prolapsed through the anus

Two days later, there was a cessation of bowel movements and gas. The paraclinical assessment included an abdominal X-ray without preparation, which showed hydro-aerial levels higher than wide with peripheral topography, a hemoglobin level of 11g/dl, hyperleukocytosis at 13,000 white blood cells/mm³, and creatinine at 10mg/dl. An exploratory laparotomy was indicated and performed on November 15, 2019. The procedure was performed under general anesthesia and tracheal intubation. The incision was midline above and below the umbilicus. Surgical exploration revealed total ileocecal intussusception. Desinvagination maneuvers were difficult and impossible.

The entire transverse colon and left colon were necrotic, prompting a subtotal colectomy. The rectal stump was closed and a right ileostomy was performed.

Figure 2 : Surgical specimen from subtotal colectomy for ileocecal intussusception prolapsed into the anus.

The surgical specimen  examined in the pathology laboratory revealed chronic inflammation of the mucosa, with no other abnormalities. The postoperative course was uneventful and the patient was followed up on an outpatient basis from the sixth postoperative day. Three months later, she underwent a second operation to restore digestive continuity, and an ileo-rectal anastomosis was performed. One month after the operation, complications arose in the form of an eventration. Six (6) months later, we repaired the eventration by inserting a Trulene prosthesis. The postoperative course was uneventful after a 12-month follow-up.

Observation 2: Mr. Y..., 49 years old, farmer, with no particular medical history, was admitted to our department on 12/07/2022 for diffuse, intermittent abdominal pain, rectal bleeding, and the presence of a pink mass prolapsing from the anus. The interview did not reveal any constipation or gas retention. Clinical examination revealed that he was in good general health, with a temperature of 37°C, blood pressure of 100/60 mmHg, and a pulse rate of 76 beats per minute. He was in good nutritional condition (BMI of 18). The abdomen was flat, supple, depressible, with no palpable mass but with hypogastric tenderness. However, examination of the anal margin revealed a purplish mass approximately 20 cm in size, prolapsed from the anus, oozing bloody mucus, and irreducible. A diagnosis of rectal prolapse was made, and abdominal rectopexy was indicated. The results of the preoperative assessment were within normal limits: creatinine level at 10.7 mg/L, blood urea at 0.11 g/L, blood glucose at 0.70 g/L, hemoglobin level at 10.7 g/dL. The patient was blood type O Rh positive. On 12/10/2022, the surgical procedure was performed under general anesthesia with tracheal intubation. After a midline laparotomy above and below the umbilicus, the exploration revealed a colo-colic intussusception involving the transverse and sigmoid colon segments.

Figure 3 : Surgical view of the colonic intussusception