S4216 When the Esophagus Turns on Itself: A Rare Case of Esophageal Intussusception

Introduction: Though more common in children, esophageal intussusception (EI) is a rare condition in which the esophagus/stomach invaginates into itself, causing acute obstruction. Here, we discuss a case of EI in an adult, emphasizing its unique presentation and management. Case Description/Methods: A 54-year-old woman with metastatic distal esophageal cancer, and a recent G-tube placement 1 week prior to admission presents for vomiting, poor oral intake, and midsternal/epigastric pressure. Computed tomography chest imaging revealed a 2.8 cm portion of the distal esophagus (intussusceptum) seen telescoping into the proximal stomach (intussuscipiens), with the malignant tumor serving as the lead point at the apex of the invaginating segment. The gastroenterology team performed an EGD which revealed no evidence of necrosis, ischemia, nor ongoing EI, suggesting that the issue had resolved. This quick resolution shifted treatment focus to symptom management. Within the next few days, her symptoms resolved, and she was able to tolerate oral intake. Her improvement allowed for an appropriate discharge with a structured enteral feeding plan. Discussion: Unlike small bowel or colonic intussusception where the bowels are not fixed to the peritoneum, the esophagus is fixed in the mediastinum, decreasing the likelihood for intussusception. While EI is not too well known, the proposed mechanism behind EI is strikingly similar to intussusception seen with a tumor/polypoid lesion serving as the lead point. Predisposing factors include anatomical alterations (cancer, hiatal hernia or prior esophageal surgery), increased intra-abdominal pressure, and poor fixation of the stomach. Presentations may include acute esophageal obstruction, respiratory distress, or upper gastrointestinal symptoms. Demonstrating an invaginated segment through imaging (esophagram, computed tomography, or endoscopy) supports the diagnosis of EI. Treatment depends on symptom severity, with conservative management (observation and supportive care with naogastric decompression and IV fluids) attempted in select cases while endoscopic or surgical intervention is required when obstruction, perforation or ischemia exists. Fortunately, our patient had resolution of her intussusception quickly, thus her symptoms improved. Awareness of EI is essential for timely diagnosis and intervention. Early recognition and appropriate management help prevent complications and ensure the best possible prognosis.