Case Presentation: A 56-year-old man with active polysubstance use disorder including daily intranasal heroin and cocaine use and previous abdominal surgery was admitted with a week of abdominal pain and constipation. His last bowel movement was one week prior to admission, though he did report ongoing flatus without nausea or vomiting. The abdomen was diffusely mildly tender to palpation, without rebound. There was no history of a recent colonoscopy. Past surgeries included exploratory laparotomy due to right abdomen stab wound and open appendectomy. Urine toxicology was positive for cocaine and opioids. Computed tomography showed colo-colonic intussusception in the ascending colon plus a large colonic stool burden (Fig. 1a). While a lead point was suspected, no mass or focal lesion was identified. Diagnostic laparoscopy was performed to exclude underlying malignancy, showing extensive omental adhesions to the colon along the midline and right lower quadrant. However, no obvious colonic intussusception or mass was seen. The procedure was terminated with a plan for a bowel prep before colonoscopy, which again showed no mass or other colonic abnormality (Fig. 1b). The patient was discharged the following day on an aggressive bowel regimen.
Discussion: Intussusception is a condition where part of the bowel slides into an adjacent segment. It is a rare condition in adults, with an incidence of around 2-3 cases per million people.Up to 90% cases of colonic intussusception are due to a structural lesion, many associated with malignancy. This can result in obstruction or even ischemia or infarction.Cocaine acts as an indirect agonist of the sympathetic nervous system by binding to the dopamine transporter. Long-term use of cocaine reduces blood flow in the gastrointestinal tract, which can lead to decreased peristalsis and ischemia. Opioids also can inhibit intestinal peristalsis by acting on peripheral mu opioid receptors in the smooth muscle. As no focal cause of intussusception was identified, reduced colonic peristalsis and even focal ischemia must be considered as possible etiologies in this patient and in similar cases where no lead point lesion is seen.
Conclusions: This case illustrates the rare presentation of opioid and cocaine-induced severe constipation leading to intussusception. It emphasizes the importance of broad differential diagnosis of intussusception particularly in cases without a lead point.
