Surgical management of intussusception in the adult

Controversy in the Treatment of Adult Long Ileocolic Intussusception: Case Report

Adult intussusception is an unusual cause of intestinal obstruction. In contrast to children, intussusception in adults is usually due to an identifiable cause. We present a case of an 81-year-old female who was diagnosed with a long intussusception on CT scan of the abdomen. Because of the likelihood of neoplasia, a right hemicolectomy was undertaken, after which the patient recovered well. The correct treatment of adult intussusception is not unanimously agreed upon. We present a case of long intussusception in which partial reduction of viable small bowel before the resection was done by applying gentle traction. This provided sufficient small bowel mesentery length, preventing any damage to superior mesenteric vessels and avoiding unnecessary excision of healthy bowel.

Transient colocolic intussusception

We present the CT findings of a transient colocolic intussusception, related to an underlying colonic tumor, but remote from it. The resolving nature of intussusception was clearly demonstrated on delayed images and may explain the characteristic chronic clinical symptoms of intussusception in adult.

Benign neoplastic polyp of the caecum as a rare cause of intussusception in adults

Images

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

PURPOSE

To determine the clinical presentation in cases of adult intussusception demonstrated at computed tomography (CT) or magnetic resonance (MR) imaging and to correlate the imaging appearance with clinical diagnosis.

MATERIALS AND METHODS

Retrospective review of CT and MR images and clinical records of all patients with an intussusception demonstrated on CT or MR images from January 1, 1991, through April 30, 1998.

RESULTS

Thirty-three patients had one or more intussusceptions demonstrated on CT (n = 30) or MR (n = 3) images. Twenty-nine patients had enteroenteric intussusceptions, and four had intussusceptions involving the colon. Ten patients (30%) had a neoplastic lead point, including all four of the intussusceptions involving the colon (benign mass, n = 3; malignant mass, n = 7). In 23 cases (70%), no neoplastic lead point was identified. A variety of causes were implicated in these cases, with 16 cases (48%) classified as idiopathic. Enteric intussusceptions in the nonneoplastic group were shorter in length (median, 4 vs 10.8 cm; P = .002), smaller in diameter (median, 3 vs 4 cm; P = .002), and less likely to be associated with obstruction (4.3% vs 50%; P = .02).

CONCLUSION

Less than one-third of adult intussusceptions demonstrated at CT or MR imaging were caused by a neoplastic lead point. Almost half of adult cases in this series were idiopathic.

Intussusception in adults: institutional review

BACKGROUND

Intestinal intussusception in the adult is a rare entity that differs greatly in etiology from its pediatric counterpart. Controversy remains regarding the optimal management of this problem in the adult patient. The purpose of this study was to determine the cause(s) of intussusception and to determine the role of intestinal reduction in the management of intussusception in adults.

STUDY DESIGN

A retrospective review performed at The Mount Sinai Medical Center identified 27 patients, 16 years and older, with a diagnosis of intestinal intussusception. Data related to presentation, diagnosis, treatment, and pathology were analyzed.

RESULTS

There were 13 males and 14 females. The median age of the group was 52 years with a range of 16 to 90 years. Abdominal pain was the most common presenting complaint. A preoperative diagnosis was suspected in 11 of 27 patients (40%). There were 22 small bowel lesions and 5 colonic lesions. A pathologic cause was identified in 85% of patients with 8 of 22 (36%) small bowel and 4 of 5 (80%) of large bowel lesions being malignant. All small bowel cancers represented metastatic disease and all large bowel malignancies were primary adenocarcinomas. The median age of patients with malignant disease was 60 years; it was 44 years for those with benign disease. Operative treatment consisted of resection alone in 58% of patients and resection after reduction in 42%. Three patients were treated nonoperatively.

CONCLUSIONS

Our data support a selective approach to the operative treatment of intussusception in adults. Colonic lesions should not be reduced before resection because they most likely represent a primary adenocarcinoma. Small bowel intussusception should be reduced only in patients in whom a benign diagnosis has been made preoperatively or in patients in whom resection may result in short gut syndrome.

Adult intussusception

OBJECTIVE

The objectives were to review adult intussusception, its diagnosis, and its treatment.

SUMMARY BACKGROUND DATA

Adult intussusception represents 1% of all bowel obstructions, 5% of all intussusceptions, and 0.003%-0.02% of all hospital admissions. Intussusception is a different entity in adults than it is in children.

METHODS

The records of all patients 18 years and older with the postoperative diagnosis of intussusception at the Massachusetts General Hospital during the years 1964 through 1993 were reviewed retrospectively. The 58 patients were divided into those with benign enteric, malignant enteric, benign colonic, and malignant colonic lesions associated with their intussusception. The diagnosis and treatment of each were reviewed.

RESULTS

In 30 years at the Massachusetts General Hospital, there are 58 cases of surgically proven adult intussusception. The patients' mean age was 54.4 years. Most patients presented with symptoms consistent with bowel obstruction. There were 44 enteric and 14 colonic intussusceptions. Ninety-three percent of the intussusceptions were associated with a pathologic lesion. Forty-eight percent of the enteric lesions were malignant and 52% were benign. Forty-three percent of the colonic lesions were malignant and 57% were benign.

CONCLUSIONS

Intussusception occurs rarely in adults. It presents with a variety of acute, intermittent, and chronic symptoms, thus making its preoperative diagnosis difficult. Computed tomography scanning proved to be the most useful diagnostic radiologic method. The diagnosis and treatment of adult intussusception are surgical. Surgical resection of the intussusception without reduction is the preferred treatment in adults, as almost half of both colonic and enteric intussusceptions are associated with malignancy.

Ileocecal intussusception of small-bowel lymphoma: diagnosis by colonoscopy

Intussusception is rare in adults. There is little information on the role of colonoscopy in colonic intussusception. We report, to our knowledge, the first adult case of small-bowel lymphoma causing ileocecal intussusception in which the diagnosis was made by colonoscopy. Colonoscopy has a useful role in the diagnosis and management of ileocecal intussusception.

The diagnosis and management of adult intussusception

BACKGROUND

While intussusception is relatively common in children, it is a rare clinical entity in adults, where the condition is almost always secondary to a definable lesion.

DATA SOURCES

Thirteen cases of intussusception occurring in individuals older than 16 were encountered at our institute between 1981 and 1994.

RESULTS

Presenting signs/symptoms included recurrent bowel obstruction, intermittent pain, and red blood per rectum. Correct preoperative diagnosis was made in six patients using colonoscopy, flexible sigmoidoscopy, upper gastrointestinal (GI) series and computed tomography (CT). At surgery the lead point was identified in the small intestine in eight cases, in the colon in four cases, and one small intestinal intussusception was considered idiopathic. Twelve patients underwent laparotomy and one patient was both diagnosed and treated by colonoscopy alone.

CONCLUSIONS

Adult intussusception is an unusual cause of bowel obstruction. The likelihood of neoplasia, particularly in the colon as a cause, is high. Operative management is thus almost always necessary.

Perineal repair of colorectoanal intussusception. Report of a case and review of the literature

Colorectoanal intussusception is a rare and distinct entity that differs from the more common rectal prolapse. Typically intussusception occurs with tumor at the apex of the intussuscepted segment acting as a lead point. Only 26 adult cases of this entity have been reported in the literature. All have been associated with a benign or malignant tumor. Here we present a case and review the literature of colorectoanal intussusception. The case presented is that of an elderly woman with a large circumferential villous tumor at its apex. Perineal resection was performed in a single stage with intravenous sedation without complication (figures). This represents only the second reported case in the English literature of a colorectoanal intussusception treated in this manner.

Laparoscopic management of intussusception caused by colonic lipomata: a case report and review of the literature

We describe the case of a 57-year-old woman who presented with colocolic intussusception due to a lipoma. The lesion was removed by laparoscopic right hemicolectomy. Benign colorectal pathology, such as colonic lipoma, is ideally suited for laparoscopic treatment.

Malignant lymphoma in the ileocecal region causing intussusception

A 67-year-old female was admitted with diarrhea. Preoperatively, we diagnosed intussusception due to malignant lymphoma in the ileocecal region by image and colonoscopic examinations. We resected the right hemicolon for the tumor, which was located mainly in the cecum, causing intussusception. The stenotic terminal ileum free of the tumor was invaginated within the cecum with infiltrating tumor, thus showing the appearance of an anthill. The growth of the tumor corresponded with Wood's constrictive type, in which intussusception rarely occurs.

Adult enteric intussusception: additional observations on enteroclysis

Enteroclysis patterns encountered in four patients with adult intestinal intussusception of different etiology--including a leiomyoma, a Peutz-Jeghers hamartoma, a metastatic colon carcinoma, and adhesions--were analyzed and compared to surgical and pathological findings. Emphasis was given not only to radiological signs indicative of impaired circulation but also to the preoperative evaluation of the stimulating cause. A "stretched spring" pattern, corresponding to increased distance between large and thick concentric rings, was found to conform to a stage of strangulation with exudation, whereas sharply demarcated fine rings in close proximity were suggestive of the absence of vascular impairment. The morphology of the underlying lesion was also shown to conform to the dynamic appearance of the intussusception. Benign submucosal, intraluminal tumors led to a long, rather permanent intussusception, with the tumor being the leading point; whereas intussusception associated with annular malignancies or adhesions was shorter and transient or partial, as fixation was present. The cause of the intussusception was correctly identified preoperatively in each case; the vascular compromise involved was also indicated, and the correlation between radiological appearances and morphology at pathology specimens was excellent.

Enteroenteric intussusception due to a metastatic malignant fibrous histiocytoma

Intussusception secondary to metastatic sarcoma is an unusual cause of small bowel obstruction. When a patient who has no history of a previous laparotomy, and has a known malignancy which metastasized hematogenously, presents with small bowel obstruction, the diagnosis of intussusception should be considered. The patient should be evaluated and treated accordingly.

Endo-anal approaches to adult sigmoido-rectal intussusception

Intussusception of intestinal lesions in the adult is an infrequent event, indeed, those occurring in the distal large bowel are quite rare. Popular management options centre on laparotomy with resection of involved bowel. Two recent cases of intussuscepting polypoid lesions of the rectosigmoid that were successfully managed using an endo-anal approach are presented.

Intussusception in the adult--a rare disease

We present two cases of intussusception in the adult. Both cases were secondary to a benign lipoma as the lead point. These cases represent typical cases of adult intussusception, a rare disease characterized by insidious onset, vague abdominal symptoms, and elusive diagnosis. A diagnostic and therapeutic approach to adult intussusception is suggested. The need to consider this rare entity in the differential diagnosis of chronic abdominal complaints in the adult is emphasized.

The CT appearances of jejunojejunal intussusception

A case of jejunojejunal intussusception is presented, in which a malignant melanoma deposit acted as the lead point. The diagnosis was made on CT and the appearances are described.

The computed tomographic appearances and clinical significance of intussusception in adults with malignant neoplasms

The computed tomography (CT) appearances of intussusception in 14 patients and the clinical follow-up of this condition in 17 adults with known primary malignant neoplasms were retrospectively reviewed. The ages of the 11 men and six women ranged from 25 to 83 years. Nine patients had been treated for malignant melanoma and the others for various primary neoplasms. Intussusception on CT was characterized by thickening of the affected bowel segment in all 14 patients and by the presence of intraluminal fat density material in 13, a concentric ring or "target" lesion in four, and an intra-luminal soft-tissue mass in nine. Five patients had intussusception, without other evidence of disease, caused by metastases in three patients, lipoma in one and idiopathic in one. Eleven of the other 12 patients had extensive disease, and one had small bowel cytomegalovirus infection. Five of these patients had more than one site of bowel involvement. Ten of the 12 patients had progression of disease on follow-up CT examinations and six died between 26 days and 7 months after diagnosis of intussusception. Intussusception may occur as the first indication of tumour recurrence or metastasis, but is more commonly a manifestation of widespread disease. However, even in patients with malignant neoplasms, it may be idiopathic or a result of benign neoplasm.

Diagnosis and treatment of adult intussusception

Twenty adults were treated for intussusception in two large hospitals from 1969 to 1988. Fourteen intussusceptions originated in the small intestine and 6 in the large intestine. Diagnosis was reached preoperatively in only 10 patients, probably due to the atypical clinical picture. In addition to a high degree of suspicion, careful examination of plain abdominal radiograph and ultrasonography are helpful in diagnosing adult intussusception. In 18 of 20 patients, an organic lesion causing intussusception was found. In six patients the cause was a malignancy. In such cases surgical treatment is necessary. In jejunojejunal and ileoileal intussusceptions, an attempt at primary reduction followed by resection or enterotomy is justified. In most cases of ileocolic, ileocecocolic, and colocolic intussusception, primary resection is the treatment of choice, especially in patients over 60 years old because of the high incidence of malignancy.