The Discrepancy Dilemma: Spontaneous Reduction of Adult Jejunal Intussusception and the Challenge of the Negative Laparotomy

The clinical management of adult intussusception remains heavily influenced by the traditional surgical dogma that operative intervention is mandatory due to the high incidence of underlying neoplastic lead points [1, 2]. However, the ubiquitous use of high-resolution multi-detector computed tomography (MDCT) in emergency settings has led to a paradigm shift, inadvertently capturing an increasing number of transient, spontaneous small bowel intussusceptions [3, 4]. This case underscores the complex "discrepancy dilemma" modern acute care surgeons face: reconciling positive high-resolution imaging with acute physiological deterioration, which ultimately led to a retrospectively negative, yet prospectively essential, laparotomy.

Historically, adult intussusceptions were presumed to be secondary to a pathological lead point in 70% to 90% of cases, making primary en bloc resection without reduction the gold standard to avoid tumour dissemination or the risk of perforating ischemic bowel [1, 5, 6]. Yet, isolated small bowel (enteroenteric) intussusceptions possess a different clinical profile. Studies show that small bowel intussusceptions lacking a discernible mass or lead point on CT imaging—especially those measuring less than 3.5 cm in length—are often self-limiting and resolve spontaneously [4, 7]. In a stable patient, these findings might warrant conservative management. However, in our patient, one of the telescoping segments measured a concerning 6.6 cm. When coupled with the patient’s profound critical illness and physiological instability, conservative observation based purely on anatomical criteria became clinically untenable [8].

The defining catalyst for surgical exploration in this case was the patient's refractory hyperlactatemia (8.4 mmol/L) despite the successful medical optimization of his diabetic ketoacidosis (DKA) and hemodynamic status. Serum lactate remains a critical, albeit non-specific, biomarker for systemic hypoperfusion and acute splanchnic ischemia [9]. Relying solely on late radiological signs of irreversible transmural ischemia—such as pneumatosis intestinalis or portal venous gas—is a hazardous strategy, as these findings often represent end-stage necrosis associated with exceedingly high mortality [10]. According to the World Society of Emergency Surgery (WSES) guidelines, an elevated lactate level combined with a high index of clinical suspicion and an abnormal CT scan strongly indicates impending bowel infarction [10]. The combination of a classic CECT "target sign" and unresolved metabolic acidosis left no safe margin for conservative management.

The intraoperative discovery of an oedematous bowel and reactive free fluid—without a mass or active telescoping—confirms that the intussusception underwent spontaneous reduction between the imaging acquisition and surgical intervention. The localized bowel edema was likely the physiological footprint of transient vascular compromise caused by the temporary telescoping [8, 10]. While a "negative" laparotomy carries inherent surgical morbidity, it must be contextualized within the high-stakes environment of acute care surgery [6]. The WSES emphasizes that when acute mesenteric ischemia is strongly suspected, early exploratory laparotomy is the definitive diagnostic and therapeutic tool; delayed surgery yields catastrophic mortality rates [10].