Bowel intussusception in adult: Prevalence, diagnostic tools and therapy

Adult ileo cecal intussusception as a manifestation of colon carcinoma: A case report

BACKGROUND

Intussusception is the invagination of a segment of the bowel into an adjacent segment. It is the most common cause of intestinal obstruction in children, but in adults, it is rare, accounting for 1% of all intestinal obstructions and 5% of all intussusceptions, with malignancy being the most common cause. In the past, it was typically diagnosed intraoperatively. However, with the availability of computed tomography for abdominal imaging, recognizing the condition's signs has become crucial. Surgical intervention is essential for managing neoplastic cases and their complications.

CASE SUMMARY

A 45-year-old female presented with severe abdominal pain encompassing her entire abdomen, abdominal distension, vomiting, and persistent constipation. Over the past two months, she has also experienced considerable weight loss. After an initial history review, examination, and imaging investigations, the patient was diagnosed with ileo cecal intussusception resulting from a colo rectal mass located in the cecum and ascending colon. This condition was surgically managed through an extended right hemi colectomy.

CONCLUSION

Intussusception is uncommon in adults, but it should be considered in patients with intestinal obstruction. Surgical intervention is essential.

The Many Faces of Intestinal Tumors in Adults, Including the Primary Role of CT Imaging in Emergencies and the Important Role of Cross-Sectional Imaging: A Pictorial Review

Background/Objectives: Small bowel tumors (SBTs) encompass a diverse range of tumor types, with benign tumors being the most prevalent. However, the incidence of malignant SBTs is increasing, particularly small bowel adenocarcinoma; this poses a diagnostic challenge for clinicians and radiologists due to the varied and nonspecific clinical and radiological presentations associated with SBTs. In fact, SBTs can present differently in emergencies, often mimicking inflammatory diseases or manifesting as complications such as intussusception, small bowel obstruction (SBO), intestinal ischemia, perforation, gastrointestinal bleeding, or metastatic disease. These tumors can remain asymptomatic for extended periods. Methods: We present a pictorial review on the role of imaging in evaluating SBTs, focusing on the emergency setting where diagnosis can be incidental. We also include some representative cases that may be useful for radiologists and residents in clinical practice. Results: Despite these challenges, contrast-enhanced computed tomography (CECT) is usually the best modality to use in emergencies for evaluating SBTs, and in some cases, a diagnosis can be made incidentally. However, when possible, multimodal imaging through cross-sectional imaging remains crucial for the non-invasive diagnosis of SBTs in stable patients, as endoscopic procedures may also be impractical. A complementary CT study with distension using negative oral contrast media, such as water, polyethylene glycol, or mannitol solutions, can improve the characterization of SBTs and rule out multiple SBT locations, particularly in small bowel neuroendocrine tumor (NET) and gastrointestinal tumor (GIST) localization. Positive water-soluble iodine-based oral contrast, such as Gastrografin (GGF), can be used to evaluate and monitor the intestinal lumen during the nonsurgical management of small bowel obstruction (SBO) or in suspected cases of small bowel perforations or the presence of fistulas. Magnetic resonance enterography (MRE) can aid in improving the characterization of SBTs through a multiplanar and multisequence study. Positron emission tomography combined with CT is generally an essential modality in evaluating metastatic disease and staging and assessing tumor prognosis, but it has limitations for indolent lymphoma and small NETs. Conclusions: Therefore, the integration of multiple imaging modalities can improve patient management and provide a preoperative risk assessment with prognostic and predictive indicators. In the future, radiomics could potentially serve as a "virtual biopsy" for SBTs, allowing for better diagnosis and more personalized management in precision medicine.

Adult ileocolic intussusception due to primary diffuse large B-cell lymphoma

Intestinal intussusception is an uncommon condition in adults. Unlike the idiopathic spontaneous occurrence in children, about half of the cases in this population are associated with malignant neoplasms. This report describes a 44-year-old male patient presenting with abdominal pain and signs of intestinal obstruction. Through a CT examination, the patient was diagnosed with ileocecal intussusception. A 3 cm lesion was found in the terminal ileum, and a segmental enterectomy was performed. An immunohistochemical analysis identified a large B-cell lymphoma. Due to the high association with tumors, the finding of intestinal intussusception in adults should be properly investigated, regardless of symptoms.

Ovarian teratoma leading to colonic intussusception: a case report

Intussusception in adults is relatively rare compared to that in children and is typically caused by underlying benign or malignant intestinal diseases. We report a case of a 40-year-old female who presented with colonic intussusception and obstruction caused by an ovarian teratoma invading a segment of the colon. Contrast-enhanced CT imaging revealed a soft tissue mass within the colon, and colonoscopy identified a large cystic lesion approximately 6.0 × 6.0 cm in size located 20 cm from the anal verge. This lesion obstructed the lumen, causing significant narrowing. Preoperatively, the condition was misdiagnosed as intussusception caused by a colonic diverticulum. During laparoscopic exploration, a left ovarian tumor invading the colon was identified as the cause of the intussusception and obstruction. Consequently, partial colectomy and left oophorectomy were performed. Histopathological examination confirmed the diagnosis of a mature ovarian teratoma. The postoperative recovery was uneventful, and the patient was discharged in good health. This case report presents a rare instance of intussusception, highlighting the challenges associated with achieving an accurate preoperative diagnosis. Surgical intervention remains the primary treatment modality for patients with this condition.

Unexpected Twists: Intussusception as a Long Term Sequalae of Bariatric Surgery

Bowel intussusception is rare in adults and accounts for less than 5 % of all cases, occurs in only 1 % of patients with bowel obstruction and in 0.64 % of patients following Roux-en-y bypass surgery with a female predominance. Our case underscores the unusual size and configuration of intussusception, wherein the distal segment telescopes into the proximal segment, defying the conventional presentation. Notably, the rarity of observing intussusception following Roux-en-Y gastric bypass surgery is also highlighted. It is important to be clinically vigilant and keep long term sequalae of bariatric surgery on the differential. A 56-year-old female with a remote history of Roux-en-Y gastric bypass surgery presented with epigastric pain radiating to the lower left and right quadrants, nausea, and vomiting of 1-day duration. She was on a prolonged outpatient course of non-steroidal anti-inflammatory drugs and steroids for pain management following recent orthopedic procedure. In the emergency department, she was afebrile, saturating well on two liters of oxygen, and normotensive with sinus tachycardia. Labs showed leukocytosis with mildly elevated lipase, alkaline phosphatase, and lactic acid. Initial CT abdomen pelvis with contrast was unremarkable. The patient continued to experience abdominal pain with worsening lactic acid. Repeat imaging revealed a 10 cm enteroenteric intussusception containing proximal jejunum with the gastric bypass Roux limb acting as the intussuscipiens. No obvious mass or lead point was identified. Ulceration/stricture at the jejunojejunal anastomosis was thought to be contributory to this. The patient underwent successful laparoscopic surgery.

Gastroduodenal intussusception in an elderly patient: A rare case

Gastroduodenal intussusception is a rare but important cause of gastric outlet obstruction, particularly in elderly patients. We present the case of an 81-year-old female who arrived at the emergency department with complaints of epigastric pain, nausea, and vomiting. A CT scan revealed gastroduodenal intussusception, while subsequent endoscopy identified a submucosal mass, raising suspicion for either a gastrointestinal stromal tumor (GIST) or pancreatic rest. This case report highlights the diagnostic process, therapeutic considerations, and clinical outcomes, with a review of the relevant literature.

Laparoscopic limited hemicolectomy for descending colo-colic intussusception in an adult

ABSTRACT

Intussusception in adults represents 1% of bowel obstructions and up to 0.02% of all hospital admissions. Amongst these, colo-colic intussusception of the descending colon forms the rarest of causes due to the fixed nature of the descending colon. Most of adult intussusceptions follow a lead point and are commonly due to colonic malignancy which may get missed on pre-operative evaluation. Surgery is usually warranted as these patients are usually symptomatic and at risk of vascular compromise, leading to perforations and obscure malignancies. We present a case of laparoscopic limited hemicolectomy and primary anastomosis in a middle-aged male who presented with colo-colic intussusception, which appeared to be following a malignant mass on imaging and lipoma on colonoscopic biopsy done twice. Keeping in mind the possibility of a malignant lead point, no attempt was made to reduce the intussusception and a vessel first approach with 5 cm margin on either side was performed.

Multiple Intussusceptions with multiple polyps as identifiable lead point: A curious case report

Intussusception is a condition in which the proximal segment of the bowel telescopes into the distal segment. 90% of the cases, especially in infants and toddlers, do not have any lead point and are due to lymphoid hypertrophy, following a viral infection. The presence of polyps in the form of lead point in children is rare. In fact, multiple polyps presenting as multiple sites intussusception are much rarer. We report a case of multiple intussusceptions in a 11-year-old female who presented with complaints of pain abdomen and blood-mixed stool. On imaging examination, she was found to having multiple polyps serving as a possible lead point, and was managed with hydroreduction. Imaging in case of multiple intussusception typically reveals concentric rings of bowel within the bowel giving a "target sign" on axial scans and a "pseudo-kidney sign" on coronal/sagittal CT scans. Our case report shows that, multiple intussusception due to multiple polyps can be a possibility for acute pain abdomen in children.

Intestinal intussusception: Uncommon occurrence in a 25-year-old female: A case report

INTRODUCTION AND IMPORTANCE

Intestinal intussusception is an uncommon condition in adults, particularly in young females, where one segment of the intestine telescopes into an adjacent segment, leading to bowel obstruction and potential compromise of blood supply. This case report presents a rare instance of intestinal intussusception in a 25-year-old female.

CASE PRESENTATION

A 25-year-old female presented to the emergency department with severe, sudden-onset abdominal pain, nausea, and vomiting. Physical examination revealed a soft abdomen with tenderness and rebound tenderness initially in the right upper quadrant, which later migrated to the left upper quadrant, along with leukocytosis. Imaging studies, including X-ray, ultrasound, and contrast-enhanced computed tomography (CT) scan, demonstrated dilated intestinal loops, a "bowel within bowel" appearance suggestive of intussusception, and a right appendiceal cyst. The patient underwent surgical intervention after failing to respond to initial conservative management.

CLINICAL DISCUSSION

Adult intussusception is rare, often presenting with non-specific symptoms that can delay diagnosis and treatment. Imaging modalities, particularly CT scans, are crucial for accurate diagnosis, localizing the intussusception, identifying lead points, and guiding management. While conservative management may be considered for uncomplicated small bowel intussusceptions, surgical intervention is typically recommended for symptomatic cases, large bowel involvement, or suspected malignancy.

CONCLUSIONS

This case highlights the importance of maintaining a high index of suspicion for intussusception in adult patients presenting with abdominal symptoms, regardless of age or gender. Early recognition through appropriate imaging, such as contrast-enhanced computed tomography (CT), and prompt management, including timely surgical intervention when conservative treatment fails, is essential to optimize patient outcomes in this uncommon but potentially serious condition.

The Importance of Abdominal Pain in the Elderly: An Unlikely Diagnosis of 17 cm Colo-Colonic Intussusception

We report an interesting case of a 17 cm colo-colonic intussusception involving the transverse colon, caecum, and distal small bowel in a previously healthy 79-year-old man. The patient presented to the emergency department with a two-day history of mild, left to right iliac fossa abdominal pain, with no other concerning symptoms. He had a CT of the abdomen and pelvis with contrast for suspected subacute bowel obstruction secondary to recurrent bowel cancer. This was reported as colo-colonic intussusception. Following a surgical review, he was transferred from the local district general hospital for an exploratory laparotomy and underwent a right hemicolectomy with primary ileocolonic anastomosis the same evening. The patient was discharged seven days later following an unremarkable post-operative recovery. Final histology confirmed a mucinous adenocarcinoma of the caecum with postoperative cancer staging as T2N0M0. Following discussion at the colorectal multidisciplinary meeting, no adjuvant therapy was advised, and he was placed on the standard colorectal cancer surveillance program for the next five years.

Primary mantle-cell lymphoma of small intestine presenting with intussusceptions: A case report and review of the literature

INTRODUCTION AND IMPORTANCE

Mantle cell lymphoma is a rare type of non-Hodgkin's lymphoma which accounts for 5 % of all cases. Patients present with an advanced form of the disease. We present here a case of ileocolic intussusception secondary to mantle cell lymphoma which was revealed by abdominal pain and vomiting that was treated by surgical resection followed by chemotherapy.

CASE PRESENTATION

This report illustrates the case of a 34-year-old male who presented with abdominal pain and vomiting. Imageology demonstrated an ileocolic intussusception which was treated with hemicolectomy followed by chemotherapy. Histopathology confirmed the diagnosis of Mantle cell lymphoma.

CLINICAL DISCUSSION

Mantel cell lymphoma is a rare type of B-cell cancer. Patients are generally diagnosed with an advanced stage of the disease. Ileocolic intussusception is an uncommon presentation. Surgery is the pillar of the treatment. Resection depends on the extent and location of the lesion. Postoperative chemotherapy is crucial and it increases survival rate.

CONCLUSION

Mantle cell lymphoma is a rare subgroup of B-cell lymphomas. Ileocolic intussusception is a complicated form of the disease. Surgery combined with chemotherapy is the mainstay of the treatment. Diagnosis is confirmed by histological analysis of the surgical specimen.

Ileocolic intussusception secondary to Peutz-Jeghers polyp: the need for oncological resection surgery

In this case report, we detail the management of a woman in her late 30s with ileocolic intussusception, emphasizing the high malignancy risk inherent in adult intussusception cases. Given the patient's acute symptoms and significant family history of ovarian and breast cancers, radical oncological resection was pursued. The surgical intervention comprised a right hemicolectomy and right ovarian cystectomy, with histopathological findings revealing a Peutz-Jeghers polyp and benign thyroid tissue, but no malignancy. This case underscores the imperative for a surgical approach that anticipates the potential for malignancy in adult intussusception, advocating for radical resection as a fundamental strategy, even in the absence of confirmed malignant histopathology, to ensure comprehensive management and alignment with oncological best practices.

Adult intussusception: a systematic review of current literature

BACKGROUND

Intussusception in adults is a rare condition characterized by a low incidence, which complicates the establishment of standardized management protocols unlike those readily available for pediatric cases. This study presents a case series from our institution alongside a systematic review of existing literature. The objective is to delineate effective management strategies for adult intussusception.

METHODS

A systematic search of databases was conducted covering the period from January 2000 to May 2024. The study focused on adult patients diagnosed with intussusception either pre-operatively or intraoperatively and managed with either surgical intervention or conservative methods. The analysis also included retrospective review of patient records from our institution, specifically targeting individuals over 18 years of age, to determine the predominant types of intussusception and identify any pathological lead points associated with these cases.

RESULTS

In our study, a total of 1,902 patients were included from 59 selected articles, with a mean age of 52.13 ± 14.95 years. Among them, 1,920 intussusceptions were diagnosed, with 98.3% of cases identified preoperatively. Computed tomography (CT) scan was the primary diagnostic modality used in 88.5% of cases. Abdominal pain was the predominant presenting symptom, observed in 86.23% of cases. Only 29 out of 1,920 cases underwent attempted reduction, while the majority required surgical resection due to the high incidence of malignancy in adult cases. The most common type of intussusception identified was colocolic (16.82%), followed by enteric (13.28%), ileocolic (4.89%), and ileocaecal (0.78%) types. A pathological lead point was observed in 302 out of 673 patients (44.84%), with a notably higher frequency of malignancy associated with colocolic intussusception.

CONCLUSION

Surgical management remains the cornerstone in treating adult intussusception, particularly in cases involving the colocolic type, where there is a significant risk of underlying malignancy. Attempts at reduction are generally avoided due to the potential risk of tumor dissemination, which could adversely impact patient outcomes. Contrast-enhanced computed tomography (CECT) of the abdomen is pivotal for accurately diagnosing intussusceptions and guiding appropriate management strategies. It is imperative to adhere strictly to oncological principles during surgical interventions to ensure optimal patient care and outcomes.

Endoscopic carbon dioxide insufflation treating malignant colonic intussusception

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Colo-colonic intussusception as a rare complication of colonoscopy with polypectomy: Two case reports

BACKGROUND

Colonoscopy is the most frequently used diagnostic and therapeutic tool for the treatment of colorectal diseases. Although the complication rate is low, it can be potentially serious. Intussusception is a rare and severe complication often associated with polypectomy. Only a handful of post-colonoscopy intussusception cases have been reported, making this study a valuable addition to the medical literature.

CASE SUMMARY

Case 1: A 61-year-old man underwent colonoscopy with polypectomy for chronic abdominal pain. The patient experienced abdominal pain 11 hours later but was still discharged after pain management. He was readmitted due to recurring pain. Computed tomography (CT) showed colo-colonic intussusception. Initial conservative management and attempts at endoscopic reduction failed; therefore, laparoscopic right hemicolectomy was performed. Histopathological examination revealed tubular adenomas in the polyps and inflammation in the resected specimens. Case 2: A 59-year-old woman underwent colonoscopy with polypectomy for a polyp in the transverse colon. She experienced upper abdominal pain, fever, nausea, and vomiting 9 hours after the procedure. Emergency CT and blood tests revealed a colo-colonic intussusception near the hepatic flexure and an elevated white blood cell count. Initial attempts at endoscopic reduction failed and conservative treatment showed no improvement. She underwent successful laparoscopic reduction and recovered uneventfully. Histopathological examination of the resected polyp revealed hyperplasia.

CONCLUSION

Post-colonoscopy intussusception in adults is rare, and polypectomy may contribute to its occurrence. Early diagnosis is crucial, with prompt CT examination serving as key. After excluding malignancies, conservative management and reduction of intussusception should be considered before surgical bowel resection.

Challenges in managing duodenal intussusception: A rare cause of gastric outlet obstruction in adults

Intussusception is a rare occurrence in adults and only 5% being adults. Ileocolic intussusception is the most common type in adults whereas duodenal intussusception (DI) is the rarest subtype due to natural retroperitoneal fixation of the duodenum. There are only a few case-reports available in the literature. Here, we aimed to present our experience of five cases with DI in adults, there operative challenges and strategies to deal with the same. Age of presentation ranged from 18-45 years, and four out of five were females. Most common presentation was partial of recurrent gastric outlet obstruction (GOO) along with weight loss. They were all diagnosed on contract-enhanced-CT scan of abdomen, and all had a lead point in form of a benign polypoidal mass arising from duodenum. Two patients were managed with local excision of polyp and retroperitoneal fixation of redundant duodenum, whereas pancreaticoduodenectomy and segmental duodenal resection was required for the other two patients. One patient was lost to follow-up without definitive treatment as was minimally symptomatic. All four operated patients had uneventful recovery post-operatively and are doing well in follow-up. DI is an infrequent occurrence and a rare etiology of GOO in adults. Most of them having benign lead point, require surgical excision of lead point with fixation of duodenum to retroperitoneum. Anatomical proximity of important structures like CBD and pancreatic duct especially at perivaterian location makes surgical resection challenging. With thorough anatomical knowledge and appropriate management, this condition can be managed well.

Small bowel lipoma and intussusception: a case report

Intussusception is defined as the telescoping of bowel into itself. Intussusception is the leading cause of bowel obstruction in children, but it is rare in adults [1, 2]. It has a pathological intramural or extramural lead point. In adults, it accounts for 1%-5% of cases of bowel obstruction [3, 4]. Unlike presentation in the paediatric population of cramping abdominal pain, bloody mucus, and palpable mass in right iliac fossa, presentation in adults can be more varied and non-specific [1, 4]. Hence, diagnosis of small bowel intussusception (SBI) can be challenging, requiring a higher degree of clinical suspicion [5]. While cases of paediatric intestinal intussusception are often primary, most adult cases are secondary to structural lesions [5]. This case is of a 57-year-old lady who presented with SBI secondary to a small bowel lipoma (SBL), reflecting the importance of considering SBL as a differential in the causes of SBI.

Adult Ileocolic Intussusception Secondary to Cecal Lipoma: A Case Report

Large intestinal intussusception is rare in adults. Among potential pathologic lead points for intussusception are lipomas, benign tumors very infrequently found in the large bowel. A 30-year-old woman presented to the emergency department with a chief complaint of generalized abdominal pain for two weeks. A computed tomography scan of her abdomen and pelvis showed an ileocolic intussusception with a lead point of 6.7 cm. The lead point appeared to be predominantly fat. A colonoscopy revealed a large, obstructing lesion in the transverse colon. The patient underwent exploratory laparotomy with a right hemicolectomy, and a pathologic diagnosis of a lipoma was made. The patient recovered from surgery without complications and returned to her normal diet three weeks after discharge. This case highlights an unusual and rare presentation of an ileocolic intussusception caused by a cecal lipoma acting as a lead point.

Small bowel intussusception - aetiology & management

PURPOSE OF REVIEW

Adult small bowel intussusception (SBI) differs in incidence, symptomatology and management from the more commonly encountered paediatric intussusception. This review spans across the multitude of causes of adult SBI, and summarises the diagnostic work-up and management options according to recent literature.

RECENT FINDINGS

There has been an increase in use of small bowel capsule endoscopy and point-of-care ultrasound for the diagnosis of acute adult SBI.

SUMMARY

A high degree of suspicion of a malignant cause of SBI is required in the adult population. Alarm clinical features include weight loss, history of malignancy, and iron deficiency anaemia. CT remains the gold standard imaging technique as it may identify the lead point and thus aid in endoscopic or surgical management. If malignancy is excluded and no lead point is identified, serology and histology may be helpful to look for inflammatory, infective and autoimmune aetiology.

Malignant Ileocolocolic Intussusception in a 19-Year-Old Male

Adult intussusception is an infrequent occurrence typically resulting from an identifiable lead point of a benign or malignant etiology. Here, we present a case of a 19-year-old male who presented to the emergency department with complaints of abdominal pain, intractable nausea, and fluctuations between bloody diarrhea and constipation. These symptoms had begun two months prior and had increased in severity, resulting in significant appetite changes. An abdominal and pelvic computed tomography scan without contrast was obtained, which showed evidence of intussusception of the ileocecum into the transverse colon with resultant small bowel obstruction. The patient underwent an exploratory laparotomy, which resulted in a partial ileocolectomy due to the presence of a 6.8 cm cecal mass with palpable mesenteric lymphadenopathy. The pathologic specimen was identified as Burkitt lymphoma based on a combination of histologic, immunohistochemical, and fluorescence in situ hybridization findings. Currently, the patient is undergoing three cycles of rituximab, cyclophosphamide, vincristine, doxorubicin, high-dose methotrexate, ifosfamide, etoposide, and high-dose cytarabine (R-CODOX-M/IVAC) per Magrath protocol for low-risk Burkitt lymphoma.

Multiple intussusceptions secondary to Peutz-Jegher's syndrome in an adult male: a case report from Pakistan

Intussusception is a medical condition characterized by invagination of the intestinal segment, causing obstruction and leading to potential complications such as ischemia, necrosis and perforation. While paediatric intussusception is well documented with a peak in ages between 4 and 36 months, adult intussusception is a rare condition usually involving a lead point. In this article, we present an uncommon case of an adult male with worsening of his long-standing lower abdominal pain for the last 2 months. Radiological test reports revealed target-like lesions demonstrating two intestinal intussusceptions, for which he underwent a small bowel anastomosis, exploratory laprotomy and resection. On receiving the histopathology report, hamartomatous polyps with features favouring Peutz-Jegher's syndrome were identified as a possible lead point.

Adult intussusception with multiple intestinal adhesions: A case report

Intussusception occurs when a part of the intestine enters another segment of the intestine causing bowel obstruction. It is common in children but not in adults with only <5% of prevalence of all intussusceptions. Most of the cases have an underlying neoplastic pathology. However, we found a case where an adult patient with 2 weeks of ileus obstruction is caused by intussusception with multiple intestinal adhesions. A 59-year-old man complained of being unable to defecate, or vomit and had a tender abdomen for 2 weeks. Contrast abdominal CT showed a dilated and thickened intestinal wall, with ileo-ileal intussusception in the distal terminal ileum, indicating a diagnosis of ileus obstruction due to intussusception. During laparotomy, intussusception was found but released spontaneously followed by ancillary findings were multiple adhesions in the ileum that caused the intussusception and obstruction. In conclusion, transient intussusception in adults with multiple adhesions has never been reported before, and a CT scan is an important clinical tool to diagnose and identify the cause of this condition. Recognizing the imaging abnormalities earlier is important to prevent further complications.

An extremely rare case of multiple small bowel intussusceptions in a 20-year-old female

Intussusception, which is characterized by the invagination of one portion of the gastrointestinal tract into an adjacent segment, is an uncommon cause of abdominal pain in adults. Given that it is typically associated with identifiable pathological abnormalities, intussusception can pose a diagnostic challenge in adults due to its rarity and nonspecific symptomatology. This report presents a unique case of multiple small bowel intussusceptions in a 20-year-old female, which emphasizes the importance of clinical suspicion and advanced imaging for an accurate diagnosis.

Where does capsule endoscopy fit in the diagnostic algorithm of small bowel intussusception?

INTRODUCTION

The investigation of small bowel (SB) intussusception is variable, reflecting the lack of existing standards. The aim of this study was to understand the role of small bowel capsule endoscopy (SBCE) to investigate this pathology.

METHODOLOGY

This was a retrospective multi-centre study. Patients with intussusception on SBCE and those where SBCE was carried out due to findings of intussusception on radiological investigations were included. Relevant information was collected.

RESULTS

Ninety-five patients (median age 39+/-SD19.1 years, IQR 30) were included. Radiological investigations were carried out in 71 patients (74.7%) prior to SBCE with intussusception being present in 60 patients on radiological investigations (84.5%). Thirty patients (42.2%) had intussusception on radiological investigations followed by a normal SBCE. Ten patients (14.1%) had findings of intussusception on radiological investigations, a normal SBCE and repeat radiological investigations that were also normal. Abnormal findings were noted on SBCE that could explain intussusception on imaging in (16 patients) 22.5% of patients. Five patients (5.3%) underwent radiological investigations and SBCE to investigate coeliac disease and intussusception. None had associated malignancy. Four patients (4.2%) underwent SBCE to investigate familial polyposis syndromes and went on to SB enteroscopy and surgery accordingly. Most patients (n = 14; 14.8%) with intussusception on initial SBCE (without prior radiological imaging) had suspected SB bleeding (n = 10, 10.5%). Four patients (4.2%) had additional findings of a mass on CT scan and went on to have surgery.

CONCLUSION

SBCE should be used to complement radiology when investigating intussusception. It is a safe non-invasive test that will minimise unnecessary surgery. Additional radiological investigations following a negative SBCE in cases of intussusception noted on initial radiological investigations are unlikely to yield positive findings. Radiological investigations following intussusception noted on SBCE in case of patients presenting with obscure gastrointestinal bleeding, may yield additional findings.

Synchronous colonal and jejunal adenocarcinomas leading to intussusception in an adult female suffering from celiac disease

Coeliac disease, a relatively rare gluten-sensitive enteropathy, correlates with small intestinal malignancies, especially lymphoma and adenocarcinoma. Any kind of masses, whether malignant or benign, in the way of natural peristaltic action may increase the probability of intussusception, telescoping invagination of the proximal segment into the distal one causing an obstruction. We report a case of synchronous adenocarcinomas of the colon and jejunum in a 3-year-old female presenting as bowel obstruction. She also had coeliac disease. During laparotomy, the surgical team encountered jejunojejunal intussusception as the cause of obstruction. There are direct relationships among coeliac disease, increased risk of adenocarcinoma, and repeated intussusceptions in the absence of mass in adults. The intussusception phenomenon in an adult necessitates investigating a more severe lead point than simple mesenteric lymphadenopathy.

Incarcerated Prolapsed Sigmoid Intussusception Presenting as Rectal Prolapse Without a Lead Point

This case series presents two patients with symptoms consistent with acute rectal prolapse. The prolapses were subsequently found to be sigmoid intussusception that had prolapsed through the anus without rectal prolapse and without any intraluminal pathology or lead point. Both were recognised on examination and underwent colonic resection rather than proctectomy.

Transient intussusception - What the sonographer needs to know

Intussusception is typically considered an acute emergency; however, the increased utilisation of medical imaging has revealed that intussusceptions can also be transient, asymptomatic and possibly physiologic. Sonographers should be aware of three categories of intussusceptions: (i) persistent intussusceptions resulting in acute abdomen and requiring urgent intervention, (ii) transient symptomatic intussusceptions which may be amenable to a 'wait-and-see' strategy and (iii) transient asymptomatic intussusceptions which almost always involve the small bowel. In particular, the incidental discovery of enteroenteric intussusceptions in children should not be confused with acute pathology. In adults, sonographers should be mindful of the frequent presence of pathological lead points and further investigations may be warranted. In this literature review, we provide an overview of transient intussusceptions, highlight important differences between children and adults and describe sonographic appearances of various intussusceptions and their mimics.

A brief review of diagnostic properties of point-of-care ultrasound for adult bowel intussusception: Making the case for ultrasound

Undifferentiated abdominal pain in adults is a common chief complaint in acute care clinics and emergency departments worldwide, representing up to 10% of visits to emergency departments. Many patients have a non-specific presentation and an initial workup with labwork, urine analysis or X-ray might not reveal a specific diagnosis. Although bowel intussusception is a primarily pediatric disease, adult intussusception is a recognized but rare cause of bowel obstruction often requiring surgical intervention. However, recent data from advanced multi-detector computed tomography imaging shows that milder or recurring cases in adults have been underrecognized. Multi-detector computed tomography is still the imaging gold standard for detecting intussusception in adults, but new data showed that sonographers with basic training using the point-of-care ultrasound approach have a reasonable accuracy in detecting this pathology. As the point-of-care ultrasound for undifferentiated abdominal pain is an emerging core skill in the acute care setting, knowledge of sonographic signs of intestinal intussusception should be included in the skill set of physicians. Sonographic findings in adults mimic pediatric cases, but different location patterns and higher malignancy rates exist in adults. In this manuscript, we will review the current literature on adult intussusception and summarize key knowledge of intestinal intussusception in adults. We will present four adult patients diagnosed with different types of adult acute bowel intussusception using the point-of-care ultrasound and describe a focused scanning approach with typical sonographic findings.

Inflammatory Myofibroblastic Tumor Presenting as a Partial Bowel Obstruction: A Case Report

Intussusception, or telescoping of the bowel, is a rare condition in the adult population that can lead to serious complications, such as obstruction or ischemia. Most cases of intussusception are idiopathic and present with a pathognomonic "target sign" on imaging. Rarely, in adults, intussusceptions can be found with lead points, some of which may be neoplastic. Treatments for intussusception include air enemas or surgical intervention if enemas are unsuccessful in resolving the telescoped bowel. This case report discusses an atypical presentation of intussusception in an adult female with a "whirlpool sign" on imaging rather than the typical "target sign." She was found to have incorporation of mesenteric fat into telescoping bowel causing edema and partial bowel obstruction. The affected bowel was removed laparoscopically, and an end-to-end anastomosis was formed. Pathology of the resected bowel revealed a non-immunoreactive inflammatory myofibroblastic neoplasm as the lead point. Most inflammatory myofibroblastic tumors stain positive for desmin, smooth muscle actin, and anaplastic lymphoma kinase (ALK), whereas this patient was non-immunoreactive. The patient tolerated surgery well and is now pain-free with normal gastrointestinal function. This case report hopes to heighten awareness of atypical presentations of intussusceptions, the use of imaging to help aid in uncertain diagnoses, and the appropriate surgical treatment for symptomatic patients.

Postoperative intussusception: a rare but critical complication in adult patients with Crohn's disease - case report and literature review

Objectives

Postoperative entero-enteric intussusception is a rare complication in adult patients with Crohn's disease (CD). The knowledge of this distinct complication and its timely diagnosis and therapy are of utmost importance to prevent fatal intestinal necrosis. There is no consensus about the optimal management of postoperative entero-enteric intussusception, although surgical exploration is widely advised.

Case presentation

In this report we describe an unusual case of postoperative jejuno-jejunal intussusception following small bowel resection in a patient with stricturing CD. Furthermore, this report offers an overview of the available literature and summarizes the best approach and management strategies for adult intussusception associated with CD.

Conclusions

Delay in diagnosis and therapy can lead to life-threatening complications. Early diagnosis and emergent surgical treatment prevent intestinal necrosis and reduce the risk of short bowel syndrome.

Predictors of malignant intussusception in adults using clinical manifestations and multidetector computed tomographic findings

PURPOSE

To investigate the diagnostic performance of clinical manifestations and multidetector computed tomographic (MDCT) features in detecting predictors of malignant intussusception in adults.

MATERIAL AND METHODS

We retrospectively reviewed 88 adults with 91 intussusceptions who were diagnosed by MDCT. Their clinical manifestations and MDCT features were reviewed and compared between the malignant and benign groups. Uni- and multivariate logistic regression analyses were used to identify independent predictors of malignant intussusception.

RESULTS

There were 61 patients in the malignant group and 27 patients in the benign group. The malignant group had older age (mean, 62.61 vs 54.22 years, P = 0.014), more colon-related intussusception (89.06% vs 55.56%, P < 0.001), shorter intussusception length (median, 6.53 vs 9.73 cm, P = 0.009), higher maximum short axis diameter (mean, 4.85 vs 4.10 cm, P = 0.001), more enlarged lymph nodes (40.63% vs 11.11%, P = 0.006) than the benign group. Lead points were mainly presented as masses, which were irregular (44.74%) and lobular (28.95%) in the malignant group, and round or oval (92.00%) in the benign group. On the unenhanced MDCT, 90.62% of them in the malignant group showed non-hypodense. Multivariate analysis showed that intussusception length (P = 0.013), maximum short axis diameter (P = 0.007), non-round/oval lead point (P < 0.001) and non-hypodense lead point (P = 0.030) were independent factors of malignant intussusception.

CONCLUSION

Malignant intussusception can be identified using independent predictors such as intussusception length, maximum short axis diameter, non-round/oval and non-hypodense lead point. When integrating these four factors, radiologists can make qualitative diagnoses withhigher sensitivity and specificity, allowing clinicians to develop more appropriate treatments.

Ileocolic neoplastic intussusception-Imaging role and surgical management: A case report

Intussusception refers to invagination of bowel loops into a neighboring, adjacent bowel segment. While it is not an uncommon entity in paediatrics-about 95% of intussusceptions occur in childhood, merely 5% of them affect the adult population. When affecting the later typically the small intestine is engaged rather than the colon. The diagnosis often represents with unspecific symptoms and is rarely considered a possibility in adults. In the past the diagnosis was typically made intraoperatively. As the Multi-Detector Computed Tomography (MDCT) of the abdomen became a referral diagnostic method, recognizing the signs of the condition is very important since some of the cases are transient, while others have an underlying malignant cause and more aggressive treatment is required. Surgical treatment planning is mandatory in those neoplastic complicated cases. The presented case report describes the role of radiology and the surgical treatment of a malignant ileocolic intussusception.

Jejunal intussusception and perforation due to enteric muco-submucosal elongated polyp: a case report and literature review

BACKGROUND

A muco-submucosal elongated polyp is a non-neoplastic growth composed of mucosa and submucosa. Although muco-submucosal elongated polyps are commonly reported in the large intestine, they are rare in the small intestine, in which they are called enteric muco-submucosal elongated polyps. We herein present a case of jejunal intussusception and perforation due to an enteric muco-submucosal elongated polyp.

CASE PRESENTATION

A 46-year-old woman presented with abdominal pain and vomiting. Computed tomography revealed jejunal intussusception, which was reduced via a nasointestinal ileus tube. Oral double-balloon endoscopy showed an elongated polyp in the proximal jejunum. The patient refused surgical resection and thus, the polyp was monitored. Six months later, the patient was readmitted with the recurrence of jejunal intussusception and underwent emergency surgery. Intraoperative findings revealed an intussuscepted bowel with an elongated polyp and multiple perforations in the proximal jejunum. We resected approximately 90 cm of the bowel, including the intussuscepted segment and perforated sites. The pedunculated polyp, which was 60 mm in length, was located on the oral side of the resected specimen. Histopathologically, the polyp was covered by normal mucosa and the submucosa consisted of edematous loose connective tissue. The histopathological diagnosis confirmed an enteric muco-submucosal elongated polyp.

CONCLUSIONS

Symptomatic patients with enteric muco-submucosal elongated polyps may be at risk of complications, as observed in the present case, and need to undergo timely resection.

Intussusception after injury to the small intestine during emergent cesarean delivery of a premature triplet pregnancy: A case report

Intussusception is a rare cause of intestinal obstruction in the postoperative setting. This report describes a rare case of intussusception in the early postoperative period following an emergent cesarean delivery of a premature triplet pregnancy, where the small intestine was fully transected. The intestine was repaired with a stapled primary side-to-side functional end-to-end anastomosis. Five days after being discharged, the patient was readmitted due to a small bowel obstruction due to intussusception. The anastomotic site was acting as the lead point, and it required resection. Bowel continuity was reestablished with a hand-sewn anastomosis in end-to-end fashion. The patient had an uneventful recovery and was discharged home. All three neonates were eventually discharged home and the patient was able to start breast feeding. This is believed to be the first case in the obstetric literature where intussusception occurred after intestinal repair of transected bowel during an obstetric emergency.

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Early bowel obstruction after a surgical procedure can be due to intussusception.

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Bowel anastomosis can be the lead point for intussusception requiring surgery.

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Both stapled and hand-sewn re-anastomosis techniques have benefits and drawbacks.

Case report: An adult intussusception caused by ascending colon cancer

Adults with bowel intussusception caused by malignant tumors are fairly uncommon. We presented a case of a 64-year-old woman whose intussusception was secondary to ascending colon cancer. A color Doppler ultrasonography of the abdomen revealed a low echo mass in the right middle abdomen. Physical examination and digital rectal examination were both unremarkable. Computed tomography (CT) revealed a concentric circle change in the colon, as well as the mesenterium and arteries. Electronic colonoscopy discovered the colonic giant proliferative lesions and stenosis. Adenocarcinoma with moderate differentiation was discovered after a biopsy. Then laparotomy showed intussusception and the tumor was located in the ascending colon. The postoperative pathological test revealed moderately differentiated adenocarcinoma in the right colon invaded the whole layer. After hospitalization, the patient was discharged without any complications. This case highlights that rational use of CT, endoscopy, and timely surgery combines an effective strategy for the treatment of adult intussusception.

Jejunojejunal intussusception with chronic bleeding caused by gastrointestinal stromal tumor: a case report and literature review

Background

Intussusception is a rare clinical condition in adults. The majority of patients present with symptoms of bowel obstruction. Intussusception is often misdiagnosed and the majority of cases are diagnosed intraoperatively. In this paper, we present a rare case of adult jejunojejunal intussusception with chronic bleeding caused by a gastrointestinal stromal tumor (GIST). We emphasize the role of contrast-enhanced computed tomography (CT) and enteroscopy in the presurgical diagnosis and the good prognosis in the high-risk GIST patient after surgery and targeted therapy.

Case Description

Herein, we present the case of a 63-year-old female patient with small bowel intussusception with chronic bleeding caused by a GIST. Her main symptoms were intermittent melena and progressive anemia. She had a 20-year history of hypertension and had never undergone previous abdominal surgery. After failure of an esophagogastroduodenoscopy and colonoscopy to locate the hemorrhagic foci in the gastrointestinal tract, contrast-enhanced CT and enteroscopy were used and a small bowel intussusception and an intraluminal mass with a bleeding ulcer was identified. The patient underwent laparoscopic partial small bowel resection, and postoperative pathological examinations showed a small intestinal GIST with a high risk of recurrence. It was suggested that the patient take imatinib regularly for at least 3 years. At the time of writing, she has remained in good health without relapse for 24 months after discharge. We also review 20 published cases of intussusception caused by small bowel GIST in the PubMed database.

Conclusions

Obscure gastrointestinal hemorrhage needs meticulous examinations to promptly determine the cause and location of bleeding. This case and literature review revealed that comprehensive surgical resection-centered treatment was the standard treatment for primary localized GISTs in patients at significant risk of relapse.

Metastatic melanoma to the small bowel causing intussusception: A case report

Introduction and importance

Melanoma is a malignant skin neoplasm with a high metastatic potential. Several reports have shown that metastatic melanoma has a predilection to metastasize to the GI tract; however, diagnosing metastatic melanoma as a cause of intussusception has been reported in only few cases with variable presentations.

Case presentation

We present the case of a 48-year-old woman with a long history of metastatic melanoma who presented with recurrent enteric intussusception due to a melanoma lesion acting as a pathologic lead point despite immunotherapy treatment. We contribute the management plan, diagnostic modalities, and surgical approach of this rare form of adult intussusception in guidance of future management plans.

Clinical discussion

The variability in presentation of adult intussusception makes diagnosis difficult and the lack of consensus on management and surgical strategies poses challenging hurdles. A diagnostic laparoscopy followed by reduction and resection of the intussuscepted lesion in a small surgical field is an effective and beneficial palliative procedure with favorable outcomes. Our patient developed intussusception despite receiving a trial of dual immunotherapy after chemotherapy.

Conclusion

It may be insufficient to control disease even with dual immunotherapy after chemotherapy. Further studies are needed to determine the optimal surgical and oncological management in treating gastrointestinal metastasis of malignant melanoma.

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Malignant melanoma has predilection to metastasize to the small bowel.

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A metastatic melanoma lesion may act as a lead point causing intussusception despite immunotherapy treatment.

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There is no consensus on management of small bowel intussusception caused by a metastatic melanoma.

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Reduction and resection of the lead point in a small surgical fieldcan be beneficial in high-risk patients.