A 27-year-old male with a past medical history of gastroesophageal reflux disease and peptic ulcer disease presented with severe abdominal pain for 3 days. The patient did not come to the emergency department immediately because he assumed the pain was a flare-up of peptic ulcer disease. He had multiple prior esophagogastroduodenoscopies (EGDs) that showed gastritis, pre-pyloric ulcers, and duodenitis. He had also been treated for H. pylori with bismuth-based quadruple therapy. The pain was sharp, 7/10 in severity, and localized to the epigastric region without radiation. The patient had associated nausea with multiple episodes of emesis. The patient denied dysphagia, diarrhea, melena, or hematochezia. The patient denies alcohol use but endorses marijuana use up to 2 - 3 g per day for 10 years and cigarette use up to 1 pack per day for 6 years.

On physical examination, he had localized severe epigastric tenderness and guarding. Vitals were within normal limits. Abnormal lab results included an elevated red blood cell (RBC) count at 6.54, low mean corpuscular volume at 74.8 (80 - 100), and high red cell distribution width at 18.2. White blood cell (WBC) count was normal. CT scan revealed small bowel intussusception (SBI) with no evidence of inflammation in the colon or appendix (Fig. 1). The patient was emergently taken to surgery for midline laparotomy. After entering the abdomen, an area of dilated small bowel with proximal and distal collapse was seen in the mid-jejunum. This section of the jejunum was carefully straightened, leading to improvement in the distension. The segment of the small bowel was carefully palpated for signs of intraluminal lesions. The small bowel was examined from the ligament of Treitz to the terminal ileum, and no abnormality could be discovered. No evidence of tumors or masses was apparent. The patient was discharged home in 2 days upon clinical improvement.

A 33-year-old female with a past medical history significant for alcohol abuse, hypertension, gallstone pancreatitis, and esophagitis presented with a 1-day history of abdominal pain, nausea, vomiting, and diarrhea. The pain was cramping in nature, periumbilical in location, and worsened over 24 h. The patient denies any episodes of hematemesis, hematochezia, or melena. She recalled previous episodes of mild cramping abdominal pain but none that matched the severity of the current episode. She reported daily marijuana use for the past 10 years.

On admission, she was afebrile, with a respiratory rate of 16/min and a heart rate of 115 beats/min with 146/88. The abdomen was soft, non-distended, and tender around the umbilicus, with no peritoneal signs. Initial laboratory work was unremarkable, including complete blood count, serum chemistry, liver test, urinalysis, and a urine pregnancy test. CT scan of the abdomen with contrast showed fatty liver, normal spleen and distal small bowel, and terminal ileum intussusception into the colon (Fig. 2). Subsequent CT enterography showed nonspecific enteritis and resolution of intussusception without perforation or obstruction. Given CT enterography findings, no surgical intervention was planned, and she was managed conservatively. Since no other cause for intussusception could be identified, she was counseled about substance use cessation. The patient subsequently underwent a colonoscopy, which showed mild diverticulosis without bleeding and a small polyp in the descending colon. The patient improved with expectant management and was discharged on day 3 with outpatient follow-up.

A 29-year-old male with no significant past medical history presented with 2 weeks of diffuse crampy abdominal pain, nausea, vomiting, and diarrhea. The patient endorsed occasional hematochezia and reduced oral intake but noted no hematemesis, melena, or constipation. The patient reported daily marijuana use of approximately 1 g for the past 8 years but denied alcohol, tobacco, or illicit drug use. He had no personal or family history of GI disease.

On admission, he was hemodynamically stable and in no apparent distress. A physical examination showed a soft, non-distended, mildly tender abdomen with no peritoneal signs. Labs were significant for an elevated WBC count at 13.56 × 10³/µL (4.2 - 10.2), and elevated lipase at 74.8 U/L (10 - 70) with normal liver tests. CT scan of the abdomen with contrast showed jejuno-jejunal intussusception in the left mid-abdomen with sigmoid and descending colon wall thickening concerning active inflammation (Fig. 3). Infectious workup was unremarkable. The patient was treated conservatively with intravenous (IV) fluids and antiemetics for nausea. The surgery team was consulted for evaluation, but no surgical intervention was necessary as the patient’s intussusception resolved with conservative management. The patient was discharged home on day 2 with outpatient follow-up.

A 36-year-old Caucasian male came to the emergency room with a chief complaint of abdominal pain, nausea, vomiting, and abdominal pain for 1 week. He reported abdominal pain mainly in the lower abdomen 5/10 in severity, cramping in nature, non-radiating with no aggravating or relieving factor. Reported vomitus was non-bilious and non-bloody. He denies any weight loss or any upper-lower GI bleeding. He reported daily marijuana use for the past 15 years but denied alcohol, tobacco, or illicit drug use. No recent travel history was noted.

On admission, his vitals were stable, and on the exam, he was noted to have mild generalized tenderness on the lower quadrant without any guarding, rigidity, or peritoneal signs. Laboratory studies showed complete blood cell count, comprehensive metabolic profile, liver chemistries, normal liver chemistry, and amylase and lipase. The patient underwent a CT of abdomen with contrast that showed multiple small bowel short segment intussusception areas without proximal dilatation (Fig. 4). Infectious workup was unremarkable. General surgery and gastroenterology were consulted for further evaluation. He was treated with conservative management with bowel rest, IV fluids, and anti-emetics. Subsequently, the next day, the patient clinically improved the complete resolution of symptoms and had bowel movements and had a small bowel follow-through series that came unremarkable. He underwent EGD that showed erosive gastritis, clean base multiple ulcers antrum (3 - 5 mm), and duodenal erythema. The patient was discharged on day 2 upon clinical improvement.