Adult intussusception detected at CT or MR imaging: clinical-imaging correlation

Chronic epigastric pain in a middle-aged man

OBJECTIVE

The objective of this article is to describe and show a number of imaging findings that are classical for an intussusception in an adult and discuss the clinical manifestations and associated findings. We also discuss the differential diagnosis of intussusception in an adult and the most likely causes.

CONCLUSION

A malignant cause of intussusception is more likely when an intussusception involves the large bowel, in which case primary adenocarcinoma of the colon is the most prevalent. Therefore, surgical resection followed by careful pathologic analysis is typically indicated in nonresolving cases. Nevertheless, when intussusception is transiently diagnosed in an asymptomatic adult, follow-up is favored over surgery.

Colonic intussusception: clinical and radiographic features

OBJECTIVE

The purpose of this article is to comprehensively survey all CT-detected ileocolic and colocolic intussusceptions at a cancer institute.

MATERIALS AND METHODS

Using the free-text string "intus," the radiology information database of Memorial Sloan-Kettering Cancer Center was searched over a 13.5-year period for abdominopelvic CT scan reports. Images were rereviewed by an attending radiologist for the presence of a bowel-within-bowel appearance involving the colon. The reference standard for a lead point was histopathologic examination or, if the tumor was not resected, an identifiable mass persisting on follow-up CT scans. Transient intussusception was defined as intussusception that resolved on follow-up CT scan without surgical removal or as intussusception with an intermittent presence on serial CT scans. Idiopathic intussusception was defined as the absence of mass or mural thickening at CT or surgery.

RESULTS

Four hundred sixty-one CT scan reports were retrieved, 138 of which mentioned intussusception as a pertinent negative. From the remaining 323 scan reports, after all exclusions (small bowel-small bowel intussusception, incomplete imaging, pediatric patients, and misinterpretations on rereview), 33 patients were shown to have 34 intussusceptions, including ileocolic (n = 11) and colocolic (n = 23) intussusceptions, on 34 CT scans. Seven intussusceptions were transient (i.e., intermittent). No patient had idiopathic intussusception. Histopathologic results were available for 22 of 34 intussusceptions. Intussusceptions were caused by colorectal cancer (n = 12), lymphoma (n = 5), metastases to the colon (n = 8), colon polyps (n = 4), and nonneoplastic causes, including lipoma (n = 3), hematoma (n = 1), and edema (n = 1).

CONCLUSION

In patients with cancer, intussusceptions involving the colon are never idiopathic. Most are due to primary colon cancer or metastatic disease and most require surgical removal. Although seven intussusceptions were transient, six were caused by neoplasia.

Post Colonoscopy Colonic Intussusception Reduced via a Laparoscopic Approach

The authors discuss a case of colon intussusception following colonoscopy successfully treated by laparoscopic reduction.

Intussusception occurs when a mass in the bowel is pulled forward by normal peristalsis, with resultant invagination of the involved bowel wall. In the absence of a mass, intussusception may be caused by functional disturbances without gross mural abnormality. Colo-colonic intussusception in adult is relatively rare and usually secondary to a definable lesion, the majority of which are malignant in nature. Idiopathic intussusception in adults is rare and its pathogenesis is poorly understood.

We present a case report of an adult colo-colonic intussusception occurring after colonoscopy, which was treated successfully with laparoscopic reduction. We speculate that the intussusception was induced by post-polypectomy mucosal edema acting as a lead point and therefore can be treated without resection.

Idiopathic adult intussusception

Intussusception is an uncommon cause of abdominal pain in adults and poses diagnostic challenges for emergency physicians, due to its varied presenting symptoms and time course. Diagnosis is thus often delayed and results in surgical intervention due to the development of bowel ischaemia. We report on a young patient who presented with an ileo-ileal intussusception in whom there were no underlying lesions identified as a causal factor.

Laparoscopic treatment of adult sigmoidorectal intussusception caused by a mucinous adenocarcinoma of the sigmoid colon: a case report

Intussusception is a rare cause of intestinal obstruction in adult patients, but is common in children. In fact, it accounts for an estimated 1% of all cases of bowel obstruction in adults, although adult intussusception of the large intestine is rare. Sigmoidorectal intussusception, however, is a rare variety with few cases reported in the literature. A mucinous adenocarcinoma, a subtype of adenocarcinoma, is characterized by extracellular mucin production and accounts for between 5% and 15% of the neoplasms of the colon and rectum. Despite the general consensus supporting surgical resections for adult intussuceptions, controversy remains over whether intussuceptions should be reduced before resection. Most cases of colon intussusception should not be reduced before resection because they most likely represent a primary adenocarcinoma. However, prior reduction followed by a resection can be considered for the sigmoidorectal intussusception to avoid inadvertent low rectal cancer sugery. We experienced one case of sigmoidorectal intussusception caused by a mucinous adenocarcinoma of the sigmoid colon in a 79-year-old woman. Abdominal computed tomography demonstrated a sigmoidorectal intussusception. After the end-to-end anastomosis-dilator-assisted reduction, the patient underwent a laparoscopic oncological anterior resection under the impression that a sigmoidorectal intussusception existed. We report a successful laparoscopic anterior resection in a patient with an intussusception caused by a sigmoid malignant tumor.

Duodenojejunal intussusception in Peutz-Jeghers syndrome: Report of a case

Recurrent intussusception is one of the common modes of presentation in patients with Peutz-Jeghers syndrome. This report presents a case of Peutz-Jeghers syndrome with synchronous duodenojejunal and jejunojejunal intussusceptions due to hamartomatous polyps. Very few cases of duodenojejunal intussusception in Peutz-Jeghers syndrome patients have so far been reported in the literature.

Association of intussusception and celiac disease in adults

INTRODUCTION

Intussusception (IS) is rare in adults. However, the more frequent use of cross-sectional imaging has resulted in an increase in its detection. Because of the reported association with celiac disease, we determined the prevalence of IS among a cohort with celiac disease.

METHODS

An anonymized prospectively maintained celiac disease database and radiological database were reviewed.

RESULTS

Of a total of 880 patients, 14 (age 47 ± 17.5 years; 50% female) had IS that was detected by CT in 10, capsule endoscopy in three, and barium studies in two. The reason for evaluation was abdominal pain in 78% (11/14), whereas in the remainder (3/14) were incidental. IS was the initial manifestation of celiac disease in 57% (8/14). Two patients were found to have lead-point intussusceptions and both had small-bowel adenocarcinoma, and 10/14 had severe villous atrophy (subtotal or total). Among those with established celiac disease, IS was detected early, within 3 years of diagnosis. Follow-up was available for 11 patients, 9 of who adhered strictly to a gluten-free diet, and six had no recurrence. Among all the patients diagnosed with IS on radiologic studies at our institution, 45 were considered to have idiopathic IS. Only two of these patients had evaluation for celiac disease.

CONCLUSION

IS occurs in celiac disease. It may be the initial presentation and is associated with abdominal pain. Adenocarcinoma needs to be excluded. The majority of patients do not have recurrent symptoms after adherence to a gluten-free diet. Celiac disease should be considered more frequently when IS is encountered.

Intussusception in adults: a retrospective study

OBJECTIVE

Intestinal intussusception in adult patients is rare. In contrast with paediatric patients, it is usually secondary to a definable lesion, often malignant. The purpose of this study was to determine the causes and the management of intussusception in adult patients.

METHOD

A retrospective review was performed looking at patients over 18 years with intestinal intussusception who were admitted to a tertiary university hospital from 1997 to 2007.

RESULT

There were 16 patients (out of whom 10 were female subjects) of mean age 49 years (range 19-76). All presented with abdominal pain and in seven (46.6%) patients, this was acute. The diagnosis of intussusception was correctly made preoperatively in eight (50%) patients. Six (37.5%) patients had the lead point for the intussusception at the ileocaecal valve, five (31.25%) in the small bowel and five (31.25%) had a colonic lead point. An anatomical cause was found in 14 (87.5%). In two (12.5%), the intussusception occurred in the postoperative period without any definable lesion. Half the patients had a malignant neoplasm. All patients underwent surgery. In 14 (87.5%) patients, this was by resection and in two (12.5%), a reduction with no resection was carried out.

CONCLUSION

The features of intussusception may be nonspecific and the diagnosis is often made only during laparotomy. An identifiable organic lesion is present in most cases. En bloc resection is recommended for ileocaecal and colocolic intussusception.

Ileocolocolic intussusception secondary to a submucosal lipoma: an unusual cause of intermittent abdominal pain in a 62-year-old woman

We present a case of subacute nonobstructing ileocolocolic intussusception secondary to a submucosal lipoma and a mobile cecum diagnosed sonographically in a 62-year-old woman. The patient was seen following a 2-month history of nonspecific intermittent pain in the right and middle abdomen and weight loss. Sonography revealed ongoing intussusception involving distal ascending and transverse colon. Analysis of the distal intussusception end demonstrated a 3.0 x 2.5 cm echogenic polypoid lesion consistent with a lipoma serving as a lead point. The sonographic diagnosis was confirmed at surgery.

A clinical overview of a retrospective study about adult intussusceptions: focusing on discrepancies among previous studies

This study was to determine clinical entity of adult intussusception, focusing on discrepancies among previous studies and to retrospectively investigate the factors associated with malignancy and survival for 10 years. In our study, 3.7% (N=42) of intussusception were adults. The most common symptom was acute abdominal pain (64.3%). Enteric, ileocolic, ileocecal, and colocolic intussusception included 52.4, 9.5, 14.3, and 23.8% of patients, respectively. Two patients (9.1%) with enteric (N=22), no patient with ileocolic (N=4), three patients (50%) with ileocecal (N=6), and five patients (50%) with colocolic (N=10) intussusception were malignant. The factor associated with malignancy was only chronic abdominal pain without acute abdominal pain (P = 0.018) and the absence of fever and ileocecal intussusception were associated with survival (P=0.010, 0.009). In our study, the most common symptom was acute abdominal pain, and enteric intussusception was the most common type. The difference in clinical presentation and location of intussusception might have resulted from small number of cases or selection of cases.

A clinical overview of a retrospective study about adult intussusceptions: focusing on discrepancies among previous studies

This study was to determine clinical entity of adult intussusception, focusing on discrepancies among previous studies and to retrospectively investigate the factors associated with malignancy and survival for 10 years. In our study, 3.7% (N=42) of intussusception were adults. The most common symptom was acute abdominal pain (64.3%). Enteric, ileocolic, ileocecal, and colocolic intussusception included 52.4, 9.5, 14.3, and 23.8% of patients, respectively. Two patients (9.1%) with enteric (N=22), no patient with ileocolic (N=4), three patients (50%) with ileocecal (N=6), and five patients (50%) with colocolic (N=10) intussusception were malignant. The factor associated with malignancy was only chronic abdominal pain without acute abdominal pain (P = 0.018) and the absence of fever and ileocecal intussusception were associated with survival (P=0.010, 0.009). In our study, the most common symptom was acute abdominal pain, and enteric intussusception was the most common type. The difference in clinical presentation and location of intussusception might have resulted from small number of cases or selection of cases.

Ileal inflammatory fibroid polyp causing chronic ileocolic intussusception and mimicking cecal carcinoma

Inflammatory fibroid polyp (IFP) is a rare, idiopathic pseudotumorous lesion of the gastrointestinal tract. While mostly reported as solitary gastric lesions, multiple cases of small bowel IFPs are also reported. It is a documented cause of intussusception in adults. In the case reports of ileal inflammatory fibroid polyps with intussusception, an emergent presentation with small bowel obstruction has been most often described. Here we depict a case of ileal inflammatory fibroid polyp presenting with chronic intermittent ileocolic intussusception, anemia and weight loss with an endoscopic appearance mimicking necrotic cecal carcinoma.

Can CT features be used to diagnose surgical adult bowel intussusceptions?

OBJECTIVE

The purpose of our study was to identify whether any CT characteristics can be used to diagnose surgical intussusceptions.

MATERIALS AND METHODS

A search of CT reports on adults revealed 118 patients with 136 intussusceptions. Two blinded readers independently reviewed the CT examinations and documented intussusception characteristics. Medical records were reviewed to determine patient outcome. Performance, interobserver agreement (A), and significance of CT characteristics to identify surgical intussusceptions were calculated.

RESULTS

Of 95,223 CT examinations, 0.13% (121/95,223) documented 136 intussusceptions over a 7-year period, of which 88.2% (120/136) were enteroenteric, 3.7% (5/136) were enterocolic, and 4.4% (6/136) were colocolic lesions or in other locations. Eight (5.9%) were surgical and 128 (94.12%) were nonsurgical lesions. Five of eight (63%) surgical lesions involved the colon. Only two of eight surgical lesions had malignant lead points. The mean sensitivity, specificity, positive predictive value, and negative predictive value for diagnosing surgical enteroenteric lesions using a measured lesion length of > 3.5 cm were 100%, 57.3%, 5.7%, and 100% (A = 0.68), respectively. Similar figures using the measured axial diameter > 3 cm were 100%, 32.9%, 3.7% and 100% (A= 0.65), respectively.

CONCLUSION

Surgical intussusceptions in adults are infrequent among the intussusceptions that are detected on CT. Most enteroenteric lesions are nonsurgical lesions, whereas lesions that affect the colon are often surgical. Many nonsurgical enteroenteric intussusceptions are longer than 3.5 cm and thicker than 3 cm, suggesting these CT features may not be useful for diagnosing surgical bowel intussusceptions in adults.

Intussusception in adults: Clinical characteristics, diagnosis and operative strategies

AIM: To evaluate 20 adults with intussusception and to clarify the cause, clinical features, diagnosis, and management of this uncommon entity.

METHODS: A retrospective review of patients aged > 18 years with a diagnosis of intestinal intussusception between 2000 and 2008. Patients with rectal prolapse, prolapse of or around an ostomy and gastroenterostomy intussusception were excluded.

RESULTS: There were 20 cases of adult intussusception. Mean age was 47.7 years. Abdominal pain, nausea, and vomiting were the most common symptoms. The majority of intussusceptions were in the small intestine (85%). There were three (15%) cases of colonic intussusception. Enteric intussusception consisted of five jejunojejunal cases, nine ileoileal, and four cases of ileocecal invagination. Among enteric intussusceptions, 14 were secondary to a benign process, and in one of these, the malignant cause was secondary to metastatic lung adenocarcinoma. All colonic lesions were malignant. All cases were treated surgically.

CONCLUSION: Adult intussusception is an unusual and challenging condition and is a preoperative diagnostic problem. Treatment usually requires resection of the involved bowel segment. Reduction can be attempted in small-bowel intussusception if the segment involved is viable or malignancy is not suspected; however, a more careful approach is recommended in colonic intussusception because of a significantly higher coexistence of malignancy.

Duodenoduodenal intussusception

Duodenoduodenal intussusception is a rare event which is usually caused by the presence of a tumor. We present a case of duodenoduodenal intussusception secondary to a large tubulovillous adenoma causing gastric outlet and biliary obstruction in a 50-year-old female. The imaging features on ultrasonography, CT, and MRI are described.

Tumor spectrum of adult intussusception

INTRODUCTION

Adult intussusception is rare. Most general and colorectal surgeons are unfamiliar with its etiology and optimal management.

PATIENTS AND METHODS

Patients older than 16 years and diagnosed with intestinal intussusception between January 1990 and June 2006 were retrospectively reviewed. Data related to presentation, diagnosis, treatment, and pathology were analyzed.

RESULTS

Seventy-two patients underwent surgery for intestinal intussusception. Neoplasm was identified as the cause of intussusception in 66 (92%) cases, and 6 (8%) were idiopathic. The incidence of malignant colonic intussusception (63%) was significantly higher than that of enteric intussusception (20%), P = 0.001. Primary colon adenocarcinoma (8 of 10 patients, 80%) and malignant lymphoma (2 of 10 patients, 20%) were the two most common underlying malignant lesions in the colon. Lipoma (15 of 40 patients, 38%) and Peutz-Jegher adenoma (10 of 40 patients, 25%) were the two most common lesions of benign small bowel neoplasms while 27% (3 of 11) of malignant enteric intussusception cases were malignant lymphoma and metastatic respectively.

CONCLUSION

Lipoma is the most common benign tumor in both small and large bowel intussusception. Whereas 80% of tumors associated with small bowel intussusception were benign, two-thirds of colonic intussusceptions had resulted from primary adenocarcinoma.

Ileocolic invagination as a complication of a cecal adenocarcinoma

Ileocolic invagination in the adult may be caused by adenocarcinoma and lead to intestinal obstruction. We report a case of a cecal adenocarcinoma that was complicated by an ileocolic invagination in a 38 year old female, diagnosed on a contrast enhanced CT scan of the abdomen and highlights the importance of contrast enhanced CT for diagnosis of ileocolic invagination.

Severe adult ileosigmoid intussusception prolapsing from the rectum: A case report

Intussusception is a pediatric condition that rarely presents in adults. In this article, we report a case of a 36 year-old man initially presenting with abdominal pain and rectal prolapse, however, surgical reduction of the rectal prolapse did no relief his symptoms. Physical examination, abdominal plain film, barium enema and colonoscopy confirmed the presence of a large intra-abdominal mass, but the origin of the mass was revealed only upon laparotomy. During the surgery, it was noted that the ileum and the sigmoid colon was connected by a 15 cm × 12cm mass, covered by an extremely dilated intestinal tissue. The resected tissue pathology demonstrated a 9 cm × 6 cm × 5 cm submucosal lipoma at the ileocecal junction without evidence of malignancy. The patient's post-surgical course was uneventful. Diagnostic and therapeutic problems related to adult intussusception are reviewed.

Linfoma ileal primário como uma causa de intussuscepção ileocecal recorrente

INTRODUÇÃO: A intussuscepção ocorre quando um segmento proximal do intestino invagina para dentro do lúmen do segmento distal adjacente. Esta patologia é relativamente comum em crianças, sendo geralmente idiopática, diferentemente do que é evidenciado em adolescentes e adultos, os quais apresentam uma causa orgânica comprovada na maioria dos casos. O linfoma intestinal como etiologia desta patologia é extremamente raro. RELATO DE CASO: Um paciente de 16 anos, masculino, referindo dor abdominal em quadrante inferior direito há 36 horas associada a vômitos e fezes com sangue vivo compareceu em nosso serviço. O exame físico se apresentava dentro da normalidade exceto por uma massa palpável no quadrante inferior direito. A ultra-sonografia abdominal revelou intussuscepção ileocecal. A colonoscopia demonstrou uma massa protuberante proveniente do orifício da válvula ileocecal que foi reduzida, tendo o paciente um alívio completo dos sintomas. Três semanas após, o paciente retornou ao nosso hospital com recorrência dos sintomas. Uma laparotomia exploradora foi realizada evidenciando uma massa polipóide no íleo terminal com intussuscepção para dentro do ceco. Uma colectomia direita ampliada foi realizada. Após exame patológico da peça e estadiamento tumoral, um linfoma de Burkitt primário foi diagnosticado. A recuperação pós-operatória não apresentou intercorrências e o paciente foi encaminhado para quimioterapia adjuvante.

Unusual causes of small bowel obstruction and contemporary diagnostic algorithm

Intestinal obstruction is a common clinical abnormality. In 60-80% of cases, the small bowel is affected. Although postoperative adhesions are responsible in 60% of cases, the other frequently observed causes are hernia, strangulation and tumours, such as carcinoid, lymphoma or adenocarcinoma. In this pictorial essay, we presented the radiological findings of uncommon causes of small bowel obstruction as well as the suggested diagnostic algorithm.

Approach to management of intussusception in adults: a new paradigm in the computed tomography era

Intussusception has been considered an operative indication in adults as a result of the risk of ischemia and the possibility of a malignant lead point. Computed tomographic (CT) scans can reveal unsuspected intussusception. All CT reports from July 1999 to December 2005 were scanned electronically for letter strings to include the keyword intussusception. Identified CT scans were analyzed to characterize the intussusception and associated findings. Clinical, laboratory, pathological, and follow-up variables were gleaned from medical records. Findings were analyzed by treatment and findings at operation. Review of 380,999 CT reports yielded 170 (0.04%) adult patients (mean age, 41 years) with intussusceptions described as enteroenteric in 149 (87.6%), ileocecal in eight (4.7%), colocolonic in 10 (5.9%), and gastroenteric in three (1.8%). Radiological features included mean length of 4.4 cm (range, 0.8-20.5 cm) and diameter of 3.2 cm (range, 1.6-11.5 cm). Twenty-nine (17.1%) had a lead point, and 12 (7.1%) had bowel obstruction. Clinically, 88 (48.2%) patients reported abdominal pain, 52 (30.6%) had nausea and/or vomiting, and 74 (43.5%) had objective findings on abdominal examination. Thirty of 170 (17.6%) patients underwent operation, but only 15 (8.8%) patients had pathologic findings that correlated with CT findings. Seven had,enteroenteric intussusceptions from benign neoplasms (two), adhesions (one), local inflammation (one), previous anastomosis (one), Crohn's disease (one), and idiopathic (one). Three had ileocolic disease, including cecal cancer (one), metastatic melanoma (one) and idiopathic (one; whereas five patients had colocolonic intussusception from colon cancer (three), tubulovillous adenoma (one), and local inflammation (one). Of the 15 without intussusception at exploration, five had pathology related to trauma, four had nonincarcerated internal hernia after Roux-en-Y gastric bypass, four had negative explorations, one had adhesions, and one had appendicitis that did not correlate with CT findings. No patient in the observation group required subsequent operative exploration for intussusception at mean 14.1 months (range, 0.25-67.5 months) follow up. All operative patients demonstrated gastrointestinal symptoms versus 55.3 per cent of the observation group (P < 0.006). Analysis of CT features demonstrated differences among patients observed without operation, those without intussusception at exploration, and confirmed intussusception with regard to mean intussusception length 3.8 versus 3.8 versus 9.6 cm, diameter 3.0 versus 3.2 versus 4.8 cm, lead point 12.1 per cent versus 30 per cent versus 53.3 per cent, and proximal obstruction 3.8 per cent versus 0 per cent versus 46.7 per cent, respectively. Intussusceptions in adults discovered by CT scanning do not always mandate exploration. Most cases can be treated expectantly despite the presence of gastrointestinal symptoms. Close follow up is recommended with imaging and/or endoscopic surveillance. Length and diameter of the intussusception, presence of a lead point, or bowel obstruction on CT are predictive of findings that warrant exploration.

Adult celiac disease: MRI findings

The purpose of our report is to describe a spectrum of findings of celiac disease at MR enterography. MR enterography is a non-invasive, feasible, and reproducible imaging technique for the evaluation of small bowel. Findings on MR enterography, similar to those of conventional barium studies, may suggest a diagnosis of celiac disease.

Adult intussusception in Asians: clinical presentations, diagnosis, and treatment

BACKGROUND

Adult intussusception is a rare clinical entity. The presentations and optimal management of adult intussusception in Asians have seldom been reported. The purpose of this study was to determine the causes and management of adult intussusception in Taiwan.

METHODS

A retrospective review performed at four medical centers in Taiwan identified 46 patients, at least 18 years old, with a diagnosis of intestinal intussusception from January 1992 to December 2005. Data related to presentations, diagnosis, treatment, and pathology were analyzed.

RESULTS

There were 28 men and 18 women with a mean age of 58 (range 19-83) years. Twenty-five patients were diagnosed with enteric intussusception and 21 patients with colonic intussusception. Disease in 35 (76.1%) patients was caused by a benign lead point. The most common symptom was abdominal pain, which was seen in all patients. Twenty-five patients presented with acute symptoms that they experienced over a period of less than 3 days. The preoperative diagnosis was 89.1% because of the wide use of abdominal computed tomography (CT). The most sensitive diagnostic modality was abdominal CT (88.6%). For all patients, 76% with enteric intussusception and 28.6% with colonic intussusception underwent operative reduction. At the time of writing, 71.7% patients were still alive. Only two patients died of postoperative complications.

CONCLUSIONS

Most patients with adult intussusception in our series were men, and most intussusceptions were benign and of enteric origin. The most sensitive diagnostic modality is abdominal CT scan. Operative reduction is recommended for enteric intussusceptions but not for colonic intussusceptions. The prognosis of adult intussusception after surgery is good except for malignant intussusception.

Clinical entity and treatment strategies for adult intussusceptions: 20 years' experience

PURPOSE

Intestinal intussusception in adults is rare and the optimal management of this problem remains controversial. The purpose of this study was to determine the causes of intussusceptions in adults and to assess their treatment.

METHODS

A retrospective review of patients older than aged 18 years who were diagnosed with intestinal intussusception at Tri-Service General Hospital between July 1984 and July 2004 was conducted.

RESULTS

During the 20-year period, there were 292 patients with intussusception, 24 (8.2 percent) of which were adults. Abdominal pain was the most common presenting complaint (79.2 percent). The diagnosis of adult intussusception was made preoperatively in 18 cases (75 percent) and intraoperatively in 6 cases (25 percent). Of the 24 patients, 20 (83.3 percent) had a defined lesion; 11 (55 percent) lesions were benign and 9 (45 percent) were malignant. In eight patients (33.3 percent), the intussusception was reduced; perforation occurred in one patient (12.5 percent). Segmental resections were performed on 14 patients (58.3 percent), right hemicolectomies on 6 patients (25 percent), laparoscopic low anterior resection on 1 patient (4.2 percent), appendectomy on 1 patient (4.2 percent), and diverticulectomy on 1 patient (4.2 percent). Intraoperative colonoscopy was performed on three patients (12.5 percent) before reduction (lipomas were noted in 2 of the patients (66.7 percent) with limited resection of the ileum and preservation of the antireflux ileocecal valve. There was one perioperative mortality (4.2 percent) and seven postoperative morbidities (29.2 percent).

CONCLUSIONS

Adult intussusception is an unusual and challenging condition and is a preoperative diagnostic problem. We discuss our 20 years of experience in treatment strategies for dealing with such unusual problems.

Adult colonic intussusception caused by cecum adenoma: successful treatment by emergency laparoscopy: report of a case

Although intestinal intussusception is relatively common in children, in adults it remains a rare clinical entity. We report an emergency laparoscopy for an adult case of colonic intussusception caused by cecum adenoma. In the present case, owing to a successful reduction via laparoscopy, the extensive intussusception could be treated with a more limited resection (wedge resection) instead of an en-bloc wide resection (right hemicolectomy). Because of the theoretical risk of perforations which could lead to the seeding of tumor cells and microorganisms into the intra-abdominal cavity, most surgeons advocate an en-bloc resection without reduction. The experience gained from the present case suggests that laparoscopy may therefore be a useful diagnostic or therapeutic tool for selected cases of adult intussusception. The choice of using either a laparoscopic approach or an open approach depends on the clinical condition of a patient, the location and extent of intussusception, the possibility of underlying disease, and the availability of surgeons with sufficient laparoscopic expertise. Additional reports may help standardize the management of this uncommon disease.

The diagnostic role of abdominal CT imaging findings in adults intussusception: focused on the vascular compromise

Intussusception is defined as telescoping of one segment of the gastrointestinal tract into an adjacent one. Unlike that in children, adult intussusception is a relatively rare condition. More than 90% of patients with adult intussusception have been reported to have an organic cause, with benign or malignant tumors for accounting for approximately 65% of the cases. In general, the diagnosis is easily made by means of computed tomography (CT) or magnetic resonance (MR) imaging. The imaging appearance of a bowel-within-bowel configuration with or without contained fat and mesenteric vessels, is pathognomonic. As the intussusceptum enters into the intussuscipiens, the mesentery is carried forward and trapped between the overlapping layers of bowel. The twisting or severe constriction of the mesenteric vessels may result in vascular compromise with subsequent edematous thickening of the involved bowel. In these circumstances, ischemic necrosis may develop if timely intervention is not undertaken. Therefore, determination of the presence or absence of intestinal necrosis in intussusception is important in patient management. On CT, the presence of well-known diagnostic CT criteria for strangulated obstruction (especially severe engorgement or twisting of the mesenteric vessels) as well as evidence of loss of the layered pattern, accumulation of extraluminal fluid collection, and bowel perforation, may suggest the diagnosis of intestinal necrosis. CT and MR imaging are limited in determining the primary disease causing intussusception. However, CT and MR provide excellent pre-operative evaluation, including the possible extension and/or dissemination of a malignant tumor. CT and MR imaging may also be useful in suggesting the presence of vascular compromise.

Transient small-bowel intussusceptions in adults: significance of ultrasonographic detection

AIM

To investigate the frequency, clinical significance, and outcome of small-bowel intussusceptions in adults detected using ultrasound in an outpatient setting.

PATIENTS AND METHODS

In two different retrospective (January 2001 to April 2003) and prospective (May 2003 to June 2005) periods, 33 small-bowel intussusceptions were found in 32 patients (13 females; mean age: 38.1 years) with known or suspected intestinal disease. Patients underwent diagnostic work-up to assess any organic disease. Patients with self-limiting intussusception were submitted to clinical and ultrasonographic follow-up.

RESULTS

Of the 32 patients with small-bowel intussusception, 25 were identified in the prospective series of 4487 examinations (0.53%) and seven in the retrospective series of 5342 examinations (0.15%; p=0.002). Four patients had persistent and 28 self-limiting intussusceptions. Self-limiting intussusceptions were idiopathic in 11 patients (39%) or associated with organic diseases in 17 (Crohn's disease in 11 patients, celiac disease in three, ulcerative colitis in one patient, and previous surgery for cancer in two). Self-limiting intussusceptions were asymptomatic in 25% of patients.

CONCLUSION

Small-bowel intussusceptions in adults are not rare and are frequently self-limiting, idiopathic, or related to organic diseases, mainly Crohn's disease and coeliac disease.

Abdominal computed tomography in refractory coeliac disease and enteropathy associated T-cell lymphoma

AIM: To evaluate computed tomography (CT) findings, useful to suggest the presence of refractory celiac disease (RCD) and enteropathy associated T cell lymphoma (EATL).

METHODS: Coeliac disease (CD) patients were divided into two groups. GroupI: uncomplicated CD (n = 14) and RCD typeI(n = 10). Group II: RCD type II (n = 15) and EATL (n = 7).

RESULTS: Both groups showed classic signs of CD on CT. Intussusception was seen in 1 patient in groupIvs 5 in group II (P = 0.06). Lymphadenopathy was seen in 5 patients in group II vs no patients in groupI(P = 0.01). Increased number of small mesenteric vessels was noted in 20 patients in groupIvs 11 in group II (P = 0.02). Eleven patients (50%) in group II had a splenic volume < 122 cm³vs 4 in groupI(14%), 10 patients in groupI had a splenic volume > 196 cm³ (66.7%) vs 5 in group II (33.3%) P = 0.028.

CONCLUSION: CT scan is a useful tool in discriminating between CD and (Pre) EATL. RCD II and EATL showed more bowel wall thickening, lymphadenopathy and intussusception, less increase in number of small mesenteric vessels and a smaller splenic volume compared with CD and RCDI.

Adult celiac disease: what is the role of MRI?

PURPOSE

To evaluate the ability of MRI to identify intra- and extraintestinal findings of celiac disease in an adult population.

MATERIALS AND METHODS

Forty-one subjects (18 men and 23 women; mean age = 41.3 years; 31 with biopsy-proven celiac disease, and 10 healthy volunteers) underwent MRI of the small bowel. MR studies were performed on a 1.5-T magnet using T2-weighted half-Fourier single-shot turbo spin-echo (HASTE) and true fast imaging in steady-state precession (True-FISP) sequences. The MR features and sensitivity, and the specificity and accuracy of some of these features are described.

RESULTS

In the 31 celiac patients, MRI showed bowel dilatation in 61.3% (N = 19), increased number of ileal folds in 48.4% (N = 15), reversed fold pattern abnormality in 38.7% (N = 12), increased wall thickness in 16.1% (N = 5), duodenal stenosis in 6.5% (N = 2), intussusception in 12.9% (N = 4), mesenteric lymphadenopathy in 41.9% (N = 13), mesenteric vascular changes in 22.6% (N = 7), ascites in 6.5% (N = 2), and no abnormalities in 12.9% (N = 4). The volunteers had unremarkable exams. The overall specificity and accuracy were 100%, and sensitivity was 79% and 75% for increased number of ileal folders and reversed fold pattern abnormality, respectively.

CONCLUSION

MRI is able to demonstrate intra- and extraintestinal features that may lead to the diagnosis of celiac disease in adults.

Adult intussusception: a retrospective review

PURPOSE

Whereas intussusception is relatively common in children, it is clinically rare in adults. The condition is usually secondary to a definable lesion. This study was designed to review adult intussusception, including presentation, diagnosis, and optimal treatment.

METHODS

A retrospective review of 22 cases of intussusception occurring in individuals older than aged 18 years encountered at two university-affiliated hospitals in Winnipeg between 1989 and 2000. The 22 cases were divided to benign and malignant enteric, ileocolic, colonic lesions respectively. The diagnosis and treatment of each case were reviewed.

RESULTS

There were 22 cases of adult intussusception. Mean age was 57.1 years. Abdominal pain, nausea, and vomiting were the commonest symptoms. There were 14 enteric, 2 ileocolic, and 6 colonic intussusceptions. Eighty-six percent of adult intussusception was associated with a definable lesion. Twenty-nine percent of enteric lesions were malignant. All ileocolic lesions were malignant. Of colonic lesions, 33 percent were malignant and 67 percent were benign. All cases required surgical interventions except one.

CONCLUSIONS

Adult intussusception is a rare entity and requires a high index of suspicion. Our review supports that small-bowel intussusception should be reduced before resection if the underlying etiology is suspected to be benign or if the resection required without reduction is deemed to be massive. Large bowel should generally be resected without reduction because pathology is mostly malignant.

Adult intestinal intussusception: CT appearances and identification of a causative lead point

The widespread application of computed tomography (CT) in different clinical situations has increased the detection of intussusception, particularly non-lead point intussusception, which tends to be transient. Consequently, determining the clinical significance of intussusception seen at CT poses a diagnostic challenge. Patients with intussusception may or may not be symptomatic, and symptoms can be acute, intermittent, or chronic, making clinical diagnosis difficult. In most cases, radiologists can readily make the correct diagnosis of intestinal intussusception by noting the typical bowel-within-bowel appearance at abdominal CT. However, the CT findings that help differentiate between lead point and non-lead point intussusception have not been well studied. Nevertheless, although there is considerable overlap of CT findings, when a lead mass is seen at CT as a separate and distinct entity vis-à-vis edematous bowel, it can be considered a reliable indicator of a lead point intussusception. Differentiating between lead point and non-lead point intussusception is important in determining the appropriate treatment and has the potential to reduce the prevalence of unnecessary surgery.