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Non-specific chronic pain is difficult to treat, especially in a patient with a complex medical history and pain in multiple regions of the body. It is important to use a multidisciplinary approach in treating such patients. In addition, it is necessary to be aware of conditions that are often non-specific in presentation such as intussusception. We describe a case report of a patient with non-specific chronic pain that was found to have intussusception.
A 42-year-old female with a past medical history of gastric adenocarcinoma status post gastrectomy with Roux-en-Y, chemotherapy that was completed the year before and left salpingo-oophorectomy for metastatic gastric carcinoma. She initially presented to the chronic pain management clinic with lower back pain for several years after failed conservative treatment. She was diagnosed with sacroiliitis and subsequently underwent bilateral sacroiliac injections of 40mg Kenalog in addition to 3ml of 0.25% Bupivacaine, which did not resolve her pain. Two weeks later, she presented to the emergency department with the chief complaint of worsening upper chest and shoulder pain that radiated to the inferior aspect of her left scapula over the past three days. Chest x-ray, troponins and EKG were all within normal limits. She was then discharged home.
Five days later, she presented with lower abdominal pain that had been persistent for the past year and left flank pain/back pain for the past four months that suddenly became intolerable. She continued to endorse post-prandial nausea, vomiting with chronic constipation. On physical examination, she had tenderness to palpation of the left lower quadrant without rebound, guarding or distention. She also had tenderness to palpation of the left flank.
A whole-body positron emission tomography computed tomography (CT) and an ultrasound of the kidneys and bladder done at this admission were negative. Previous MRI of the lumbar spine, bone scan and small bowel series were negative. Urine analysis and post-void residual were negative. CT of the abdomen with IV contrast, as shown in Figure 1, demonstrated segmented jejunojejunal intussusception with edematous bowel wall. She subsequently underwent an exploratory laparotomy with reduction of a retrograde intussusception wand bilateral transversus abdominis plane blocks. No obvious mass or lead point were identified. In her follow-up appointment, her abdominal, flank and back pain were minimal and she was improving overall.
Intussusception is a common cause of intestinal obstruction in children but is a rare cause in adults. Due to its non-specific presentation, it is difficult to diagnose. Some patients present with chronic or intermittent vague abdominal pain with nausea and vomiting, abdominal distension with partial obstruction, and rarely a palpable mass on physical examination.  While it is often idiopathic in children, adults often have a lead point to indicate another condition. Some of the causes include inflammatory bowel disease, previous Roux-en-Y, inflammatory fibroid polyp, postoperative adhesions, Meckel’s diverticulum, benign and malignant lesions and jejunostomy feeding tubes. [1,2,3] With an increase in Roux-en-Y surgeries, there has been an increase in intussusception as a complication. 
Ultrasounds are useful in the diagnosis of intussusception but CT with IV contrast is the most useful diagnostic tool for the evaluation of intussusception. Surgery is the definitive treatment for adult intussusception.
As we treat patients with chronic pain that do not have an improvement with conservative treatment in addition to more invasive treatment such as glucocorticoid injections, there needs to be a workup for medical conditions in the rare case that they are the cause.
Shakibai N, Clemans, R Intussusception- a rare cause of non-specific chronic pain: a case report. American Society for Regional Anesthesia (ASRA) Annual Pain Conference; 2022 November 17-19; Orlando, FL.
American Society for Regional Anesthesia (ASRA) Annual Pain Conference; 2022 November 17-19; Orlando, FL.