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.

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.

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.

Surgical management of intussusception in the adult

Controversy concerning the appropriate surgical management of intussusception in the adult prompted review of the Mayo Clinic's experience with this uncommon entity. During the last 23 years, 48 patients had documented intussusception: 24 instances of intussusception originating in the small intestine and 24 instances of intussusception originating in the colon. Two-thirds of the colonic intussusceptions were associated with primary carcinoma of the colon. Only one-third of the intussusceptions of the small intestine were harbingers of malignancy, and 70% of these lesions were metastatic. Because of these findings, we advocate resection of intussusceptions of the colon without initial surgical reduction, in order to minimize the operative manipulation of a potential malignancy. In the patient with intussusception of the small intestine, an associated primary malignancy is uncommon. Initial reduction, followed by limited surgical resection, is the preferred treatment. Surgical resection without reduction is favored only when an underlying primary malignancy is clinically suspected.

Clinical spectrum and surgical approach of adult intussusceptions: a multicentric study

BACKGROUND

The preoperative diagnosis of adult intussusceptions (AIs) remains difficult, and the assessment of the radiological methods has been evaluated very little in the literature. The aim of this study was to evaluate the interest of the different imaging modalities for the preoperative diagnosis of AI and describe causes of AI.

PATIENTS AND METHODS

Consecutive patients of 15 years and older with the postoperative diagnosis of intussusception from 1979 to 2004 were reviewed retrospectively for this multicentric study. Data concerning clinical considerations, morphological examinations, surgical procedure, histological conclusions, mortality rate and recurrence were analysed.

RESULTS

Forty-four patients with documented intussusception were included. The mean age was 51 years (15-93 years). The preoperative diagnosis of intussusception was made in 52% of the cases. The sensitivities of the different radiological methods were abdominal ultrasounds (35%), upper gastrointestinal barium study (33%), abdominal computed tomography (CT) (58%) and barium enema (73%). An organic lesion was identified in 95% of the cases. There was 29 enteric and 15 colonic (including appendicular) intussusceptions. Thirty-seven percent of the enteric lesions were malignant, and a bit less than 50% of them were metastatic melanomas. The benign enteric lesions were Meckel's diverticulum and Peutz-Jeghers syndrome in half of the cases. Fifty-eight percent of the pure colonic lesions (excluding appendix) were malignant, and 85% of them were primary adenocarcinomas. The benign colonic lesions were lipomas in 80% of the cases. All patients, except one, had a surgical treatment, and 13 of them had a complete reduction of the intussusception before resection. The mortality rate was 16% and recurrence occurred in three patients; two of them had a Peutz-Jeghers syndrome.

CONCLUSION

Intussusception rarely occurs in adults, but nearly half of their causes are malignant. The CT scan is a helpful examination for enteric intussusceptions whether barium enema seems to be the most performing method for colonic lesions. Surgery is the recommended treatment, with or without a primary reduction of the intussusception. During the surgical procedure, this reduction can lead to a more limited bowel resection.

Paediatric intussusception

Intussusception is one of the commonest causes of intestinal obstruction in infants and accounts for about 700 hospital admissions each year in England and Wales. Improved results of treatment have followed recent technological developments, which include ultrasonographic imaging and pneumatic reduction techniques. Most intussusceptions can be reduced successfully without the need for operation but close cooperation between surgeon and radiologist is essential. Mortality and morbidity rates from the condition have progressively declined in recent decades but avoidable deaths still occur.

Intussusception in children: current concepts in diagnosis and enema reduction

Intussusception cannot be reliably ruled out with clinical examination and plain radiography. However, a contrast material enema study and ultrasonography (US) allow definitive diagnosis of intussusception. The components of an intussusception produce characteristic appearances on US scans. These appearances include the multiple concentric ring sign and crescent-in-doughnut sign on axial scans and the sandwich sign and hayfork sign on longitudinal scans. Indicators of ischemia and irreducibility are trapped fluid at US and absence of blood flow at Doppler imaging. The aim of enema therapy is to reduce the greatest number of intussusceptions without producing perforation. Barium, water-soluble contrast media, water, electrolyte solutions, or air may be used with radiographic or US guidance. The differences in reduction and perforation rates between the various types of enemas are probably due more to perforations that occurred before enema therapy and the pressure exerted within the colon than to the contrast material used. The pressure within the colon is more constant with hydrostatic reduction than with air reduction; this fact may explain the lower risk of perforation with hydrostatic reduction. Radiation exposure is lower with air enema therapy than with barium enema therapy and is absent in US-guided enema therapy.

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 intussusception: case reports and review of literature

Adult intussusception occurs infrequently and differs from childhood intussusception in its presentation, aetiology, and treatment. Diagnosis can be delayed because of its longstanding, intermittent, and non-specific symptoms and most cases are diagnosed at emergency laparotomy. With more frequent use of computed tomography in the evaluation of patients with abdominal pain, the condition can be diagnosed more reliably. Treatment entails simple bowel resection in most cases. Reduction of the intussusception before resection is controversial, but there is a shift against this, especially in colonic cases. Surgical treatment can be difficult in gastroduodenal and coloanal intussusceptions, sometimes requiring innovative techniques. This paper presents the diagnosis and management of four cases of adult intussusception, followed by review of the literature.

The diagnosis and treatment of adult intussusception

BACKGROUND

Intussusception in adults is often diagnosed on computed tomography (CT), and the optimal treatment of this entity is not universally agreed upon. We report our experience in an attempt to clarify the usefulness of CT scan and the optimal treatment of this entity.

STUDY

Seven cases of adult intussusception were encountered at our institute between 1991 and 2001. Data related to presentation, diagnosis, treatment, and pathology were analyzed.

RESULTS

Preoperative diagnosis was made in four patients by CT scan and/or ultrasonography. Two patients had colonic cancer and one had jejunal cancer. Three of four patients with small bowel intussusception underwent reduction before resection and the other one underwent resection without reduction because of severe ischemic bowel.

CONCLUSIONS

The CT scan is most useful in making the diagnosis of intussusception. Colonic lesions should be resected without reduction. Small bowel lesions should be reduced only in patients in whom a benign diagnosis has been strongly suggested preoperatively or in patients in whom resection may result in short gut syndrome.

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.

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.

Intussusception: indications for ultrasonography and an explanation of the doughnut and pseudokidney signs

Ultrasonography has been shown to be valuable in the detection of intussusception, but a question arises, as to just when this study should be performed. Should it be a general screening procedure or should it be utilized for specific cases only? Upon reviewing the literature, and the findings in 14 of our patients, we feel that it should be utilized as a general screening procedure. In addition, we offer a different explanation for the typical doughnut and pseudokidney signs seen with intussusception.

Intussusception in adults: an unusual and challenging condition for surgeons

BACKGROUND AND AIMS

Intestinal intussusception in adults is a rare entity and there is an ongoing controversy regarding the optimal management of this problem. The purpose of this study was to determine the causes and management of intussusception in adults.

PATIENTS AND METHODS

A retrospective review of patients more than 18 years of age with a diagnosis of intestinal intussusception between January 1996 and December 2003 was conducted. Data related to presentation, diagnosis, treatment, and pathology were analyzed.

FINDINGS

A total of 13 patients were operated on due to intestinal intussusception. There were 6 men and 7 women with a mean age of 45 years (range 24--61 years). Abdominal pain was the most common presenting complaint (100%). Eight (61.5%) patients presented with acute symptoms and underwent emergency laparotomy. The diagnosis of gastrointestinal intussusception was made preoperatively only in 4 (30.7%) patients by abdominal ultrasonography and computerized tomography. The lead point of intussusception was located in the small intestine in 10 (76.9%) patients, in the colon in 2 (15.4%), and in the ileocecal valve in 1 (7.7%). A pathologic cause for the intussusception was identified in 12 (92.3%) cases and 1 (7.7%) was idiopathic. Of the cases with a defined cause, 58% of the cases were benign and 42% were malignant. Forty percent of cases of small bowel intussusception and 33.3% of cases of colonic intussusception were due to malignant lesions. All cases of small intestinal intussusception were reduced and no perforation occurred. Segmental intestinal resection was performed in 9 patients and excision of the Meckel's diverticulum was made in 1. In cases of colonic intussusception, reduction was not attempted and en-bloc resection was carried out. No perforation or spillage of the contents of the intussusception was observed. There was no surgical mortality.

CONCLUSION

Adult intussusception is an unusual and challenging condition that represents a preoperative diagnostic difficulty. We think that colonic intussusceptions should be resected in an en-bloc manner without reduction due to the risk of perforation and spillage of micro-organisms and malignant cells, whereas cases of small intestinal intussusception can be reduced without complications unless there is strangulation.

Three-year surveillance of intussusception in children in Switzerland

OBJECTIVE

We attempted to obtain baseline data on the incidence of intussusception and its association with gastroenteritis in a cross-sectional observational study in children.

METHODS

Admissions to all 38 pediatric units in Switzerland because of intussusception were reported to the Swiss Pediatric Surveillance Unit from April 2003 to March 2006. Patient and disease characteristics were assessed prospectively with the use of a standardized questionnaire based on the case definition for intussusception developed by the Brighton Collaboration. Completeness of reporting was verified through capture-recapture analysis.

RESULTS

There were 294 patients with reported intussusception; 35 cases were excluded for various reasons, and 29 additional patients were identified through International Classification of Diseases, 10th Revision, codes. After capture-recapture analysis, we estimated underreporting to the Swiss Pediatric Surveillance Unit to be 32% and we calculated a true number of 381 intussusception episodes. The highest level of diagnostic certainty was reached by 248 patients, and 20 fulfilled level 2 criteria; for the remaining 20 patients, available information was insufficient. The mean age of the patients was 2.7 years. The yearly mean incidence of intussusception was 38, 31, and 26 cases per 100,000 live births in the first, second, and third year of life, respectively, with no apparent seasonality. Seventy patients had a history of coinciding gastroenteritis, and 5 of 61 tested positive for rotavirus. Spontaneous devagination was observed for 38 patients; enemas reduced intussusception successfully in 183 cases, whereas surgical treatment was required in 67. All patients recovered without sequelae.

CONCLUSIONS

This is the first prospective nationwide surveillance of intussusception in childhood using a standardized case definition. Most cases occurred beyond infancy, and association with rotavirus gastroenteritis was rare.

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.

Intussusception. Part 3: Diagnosis and management of those with an identifiable or predisposing cause and those that reduce spontaneously

In the previous two parts of this review on intussusception, the diagnosis and management of symptomatic, "idiopathic" ileocolic and ileoileocolic intussusceptions, which are considered to result from hyperplasia of lymphoid tissue in the distal ileum, were discussed. In this third part, those intussusceptions with an identifiable cause including pathologic lead point, those due to gastrojejunostomy or other feeding tubes, and those that are seen in the postoperative period as well as those that may be asymptomatic or may reduce spontaneously (usually limited to the small bowel) are discussed.

Intussusception in adults

Images

Leading points in childhood intussusception

Children whose intussusception is caused by a specific pathologic lesion are harder to diagnose and have a higher morbidity than those with the idiopathic variety. We have collected and analyzed 31 such cases found in a series of over 500 intussusceptions. The average age of these children was greater than is usually found in most cases, and the duration of the signs and symptoms was also longer than is usually seen. Almost 50% presented with a picture of advanced small bowel obstruction. Fewer barium enemas were done (50%) and none was successful in reducing the intussusception. There was a higher number of ileo-ideal intussusceptions in this group. The commonest leading points were Meckel's diverticula, polyps, and duplications. All patients with leading points required operation; three-fourths had a bowel resection performed. This study of 569 cases suggests that older children with intussusception and children with recurrent intussusception do not necessarily have leading points causing their intussusceptions.

Intra-abdominal manifestations of Henoch-Schönlein purpura

Gastrointestinal involvement occurs in approximately two thirds of children with Henoch-Schönlein Purpura (HSP) and usually is manifested by abdominal pain. Abdominal symptoms precede the typical purpuric rash of HSP in 14-36%; the symptoms may mimic an acute surgical abdomen and result in unnecessary laparotomy. Major complications of abdominal involvement develop in 4.6% (range 1.3-13.6%), of which intussusception is by far the most common. The intussusceptum is confined to the small bowel in 58%; its frequent inaccessibility to demonstration by contrast enema means that ultrasonography is the investigation of choice. Ultrasonography complements serial clinical assessment, clarifies the nature of the gastrointestinal involvement and reduces the likelihood of unnecessary surgery. Bowel ischaemia and infarction, intestinal perforation, fistula formation, late ileal stricture, acute appendicitis, massive upper gastrointestinal haemorrhage, pancreatitis, hydrops of the gallbladder and pseudomembranous colitis are seen infrequently. Earlier diagnosis and prompt treatment of intra-abdominal complications has reduced the mortality from 40% to almost zero.

Ultrasonographic appearance of adult intussusception

A gray scale ultrasound evaluation of a case of adult intussusception is presented. The observed "target-like" abdominal mass, with central dense echoes and peripheral sonolucency, may be characteristic of this entity. A primary bowel or intestinal loop process should be considered when a lesion with this appearance is encountered.

Open-magnet MR defaecography compared with evacuation proctography in the diagnosis and management of patients with rectal intussusception

OBJECTIVE

The aim of this study was to determine whether open-magnet magnetic resonance (MR) defaecography could provide more useful clinical information than evacuation proctography (EP) alone in the evaluation of a cohort of patients with full-thickness rectal intussusception and could assist in decisions concerning management.

METHODS

Ten patients (4 male; median age 43, range 30-65) with symptomatic circumferential rectal intussusception diagnosed on EP, underwent open-magnet MR defaecography. Pathologies visible with each technique were recorded and 12 parameters of anorectal configuration and morphology measured and compared.

RESULTS

There was discordance in the diagnosis of rectal intussusception in three cases. In another two patients, MR defaecography demonstrated mucosal descent only. Measurements of anorectal configuration and morphology were similar between techniques; only rectal size and lateral dimensions of the rectocoele were significantly different, being smaller on MR defaecography than EP. Two patients were shown on MR defaecography to have significant bladder descent and two female patients had significant vaginal descent.

CONCLUSION

EP remains the first line investigation for the diagnosis of rectal intussusception, but may not distinguish mucosal from full-thickness descent. MR defaecography further complements EP by giving information on movements of the whole pelvic floor, 30% of the patients studied having associated abnormal anterior and/or middle pelvic organ descent. If surgery is planned for patients with rectal intussusception, MR defaecography provides useful information regarding the presence and degree of anterior pelvic compartment descent that may need to be addressed if a good functional outcome is to be achieved.

Meta-analysis: the clinical features of the duodenal duplication cyst

BACKGROUND

Duplication cyst of the duodenum is rare. This study describes a case of duodenal duplication and evaluates its clinical features through a literature review.

METHODS

A case of duodenal duplication is reported, and related articles published from 1999 to 2009 on PubMed were reviewed. Clinical manifestations, diagnostic examinations, and methods of management were analyzed.

RESULTS

Including this report, there had been 38 citations in literature that provide adequate descriptions of 47 cases of duodenal duplication cysts. Nineteen (40.4%) were discovered before 10 years of age, whereas 10 (21.3%) were found in the second decade. The remaining 18 patients (38.3%) were older than 20 years. The case number decreased as age increased. Overall, 80% of cases presented with abdominal pain, and 53% were complicated with pancreatitis.

CONCLUSIONS

The most common symptom in duodenal duplication cysts is abdominal pain with or without nausea or vomiting. The most common complication is pancreatitis. Differential diagnoses of pancreatitis, hepatitis, cholestasis, or intussusception should include duplication cyst of the duodenum.