Presentation
Bowels not open for 4 days. Bowel obstruction.
Patient Data
The large bowel is dilated and there is some thumb-printing in keeping with wall edema.
Abnormally dilated large bowel loops due to intussusception of the sigmoid colon. The small bowel is non-dilated (suggesting a competent ileocecal valve). The remaining abdominopelvic appearances are within normal limits.
The histology report showed "moderately differentiated adenocarcinoma arising from a tubular adenoma invading muscularis propria with no lymphovascular, venous or perineural invasion; no tumor deposits or metastatic carcinoma in lymph nodes (0/17), stage (TNM8) -pT2, pN0; R0 On immunohistochemistry, invasive adenocarcinoma cells show positive nuclear staining with all MMR proteins MLH1, PMS2, MMSH2 and MSH6.
The staining is patchy and weak especially with MLH1 and MSH6. Similar staining is noted in adjacent stromal cells in the tumor.
Interpretation: No complete loss of expression of MMR proteins. There is no evidence of mismatch repair deficiency. CDX2 is diffuse and strong positive."
Case Discussion
The case highlights how bowel intussusception in adults is almost always due to a pathological lead point (for example, lymphoma, melanoma or adenocarcinoma as was histologically proven in this case). The patient ended up with a Hartmann procedure.
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