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A rare case of gastro‐gastric intussusception in familial adenomatous polyposis

Intussusception involves the gastrointestinal (GI) tract telescoping upon itself at any point along its length, however gastro-gastric intussusception is extremely rare. Adults account for only 5% of intussusception cases and the mechanism in adults commonly involves a polyp acting as a lead point, distorting normal bowel peristalsis. Familial Adenomatous Polyposis (FAP) involves a mutation in the Adenomatous Polyposis Coli gene resulting in polyposis along the entire length of the GI tract. Despite the association with extensive polyposis, few cases of intussusception have been reported in the setting of FAP. Here we present the first reported case of gastro-gastric intussusception in the setting of FAP. A 43-year-old female, with known FAP, presented to a provincial New Zealand hospital with 6 hours of epigastric colic and vomiting. The patient had an extensive surgical history including panproctocolectomy and ileal pouch (age 32), excision of a large abdominal wall desmoid tumour with mesh reconstruction and multiple previous polypectomies. She had not had endoscopic surveillance for the last 5 years as she had relocated. Computed Tomography (CT) of the Abdomen/Pelvis demonstrated gastro-gastric intussusception and a large polypoid mass in the stomach. (Figs. 1 and 2). The heterogenous mass was approximately 150 mm and involved the body and antrum of the stomach. The proximal stomach invaginated into the remainder of the stomach forming a horseshoe-type configuration consistent with gastrogastric intussusception (Fig. 1). The patient proceeded to acute theatre for laparotomy and gastroscopy. Through a midline laparotomy, the intussusceptum was reduced from the first part of the duodenum to its original position. Gastroscopy revealed diffuse gastric polyposis, with the entire stomach carpeted by various sized polyps (Fig. 3). Several large polyps with adenomatous appearance arose from the fundus and were dusky, suggesting they formed the lead point (Fig. 3). Frozen section suggested the large polyps were adenomas without neoplasia. Following consultation with a tertiary centre Upper GI Surgeon, a total gastrectomy with Roux-en-Y reconstruction was performed. Total gastrectomy was opted for due to the widespread