Page 1 of 11 Review Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY) For citation purposes: Ongom PA, Kijjambu SC. Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management. OA Emergency Medicine 2013 Aug 01;1(1):3. Compeng interests: none declared. Conflict of interests: none declared. All authors contributed to concepon and design, manuscript preparaon, read and approved the final manuscript. All authors abide by the Associaon for Medical Ethics (AME) ethical rules of disclosure. Reflections On Clinical Practice Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management PA Ongom*, SC Kijjambu Abstract Introduction Adult intussusception is a rare cause of intestinal obstruction. Its occur- rence often presents clinicians with a diagnostic conundrum owing to its broad variation in clinical presenta- tion. Over the last half century, stud- ies have continuously contributed to the better understanding of the aeti- ology, diagnosis and treatment. The aim of this review is to discuss acute and chronic disease management in adult intussusception. Discussion The aetiology has multiple dimen- sions to its description. These in- clude its location in the gastrointes- tinal tract, presence or absence of a physical or functional initiating le- sion (lead point) and the behavioural characteristics of this lead point, be it benign or malignant. The symptoms and signs of intussusception are wide ranging, making it have a presenta- tion anywhere between an acute and a chronic intestinal obstruction. Radi- ological investigations for diagnosis can be quite accurate in the hands of skilled and experienced radiologists. The hallmark of treatment is open or laparoscopic (operative) surgery. Conclusion This clinical entity calls for a high index of suspicion coupled with rel- evant radiological investigations in its diagnosis. We are observing a trend in which unique aetiologies are being unveiled to add to an eve- growing list. Even with the standard treatment being essentially surgical, there is an increasing trend towards the use of novel surgical methods such as advanced colonoscopic and laparoscopic techniques. All these factors have prompted us to generate a critical review of the literature on adult intussusception so as to give a better holistic picture of the essential critical clinical care. Introduction Adult intussusception is a rare dis- ease. The lower age limit for ‘adults’ has never been conventionally fixed. Most institutions lean towards 12 years of age. Its clinical features, di- agnosis and treatment bring out a lot of debate among clinicians. It has a presentation ranging from the clas- sical to the atypical forms. The first clinical case of intussusception was reported in 1674 by Barbette of Am- sterdam. John Hunter documented its description in 1789 1 , known as ‘intosusception’ at the time. Almost a century later, the first successful op- eration was performed on a child by Sir Jonathan Hutchinson 2 . Adult intussusception constitutes less than 5% of intussusception cas- es 3,4 . Its incidence in resource-rich countries is 2–3 per 1,000,000 of the population per year 5 . There is a male to female ratio of 1.8:1 5 . This ratio is debatable as some studies show fe- male dominance 6,7 . More recent re- views have paid less attention to the sex ratio 3 . It is the cause of 1%–3% of all cases of intestinal obstructions 5,8 , although a contrasting African se- ries ranked it as the fourth leading cause 9 , and accounts for less than 1% of hospital admissions 10 . There is a demonstrable cause in the major- ity of cases, usually an intraluminal neoplasm. Prominent reviews point to a 70%–90% existence of an un- derlying pathological cause 4,5,8,11,12 . These are mainly polyps and colonic malignancies. In contrast, childhood intussusception is a leading cause of intestinal obstruction. The treat- ment of the condition has always had some controversy. However, most au- thorities over the years have tended to agree on one common point—the treatment is surgical. This review discusses how to manage acute and chronic diseases in adult intussus- ception. Discussion The authors have referenced some of their own studies in this re- view. These referenced studies have been conducted in accordance with the Declaration of Helsinki (1964) and the protocols of these studies have been approved by the relevant ethics committees related to the insti- tution in which they were performed. All human subjects, in these refer- enced studies, gave informed consent to participate in these studies. Pathophysiology Intussusception is defined as the telescoping or invagination of one segment of gut into another. This is predominantly in a proximal to distal direction, the natural physiological peristaltic process. The mechanism for initiation of the invagination is not clear. It is postulated that any le- sion in the bowel wall or an irritant within its lumen may alter the normal peristaltic pattern and can trigger an * Corresponding author Email: [email protected]Department of Surgery, School of Medicine, Makerere College of Health Sciences, Makerere University, Kampala, Uganda
Transcript
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For citation purposes: Ongom PA, Kijjambu SC. Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management. OA Emergency Medicine 2013 Aug 01;1(1):3.
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Refle
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ice Adult intussusception: a continuously unveiling clinical
complex illustrating both acute (emergency) and chronic disease management
PA Ongom*, SC Kijjambu
AbstractIntroductionAdult intussusception is a rare cause of intestinal obstruction. Its occur-rence often presents clinicians with a diagnostic conundrum owing to its broad variation in clinical presenta-tion. Over the last half century, stud-ies have continuously contributed to the better understanding of the aeti-ology, diagnosis and treatment. The aim of this review is to discuss acute and chronic disease management in adult intussusception. DiscussionThe aetiology has multiple dimen-sions to its description. These in-clude its location in the gastrointes-tinal tract, presence or absence of a physical or functional initiating le-sion (lead point) and the behavioural characteristics of this lead point, be it benign or malignant. The symptoms and signs of intussusception are wide ranging, making it have a presenta-tion anywhere between an acute and a chronic intestinal obstruction. Radi-ological investigations for diagnosis can be quite accurate in the hands of skilled and experienced radiologists. The hallmark of treatment is open or laparoscopic (operative) surgery.ConclusionThis clinical entity calls for a high index of suspicion coupled with rel-evant radiological investigations in its diagnosis. We are observing a trend in which unique aetiologies
are being unveiled to add to an eve-growing list. Even with the standard treatment being essentially surgical, there is an increasing trend towards the use of novel surgical methods such as advanced colonoscopic and laparoscopic techniques. All these factors have prompted us to generate a critical review of the literature on adult intussusception so as to give a better holistic picture of the essential critical clinical care.
IntroductionAdult intussusception is a rare dis-ease. The lower age limit for ‘adults’ has never been conventionally fixed. Most institutions lean towards 12 years of age. Its clinical features, di-agnosis and treatment bring out a lot of debate among clinicians. It has a presentation ranging from the clas-sical to the atypical forms. The first clinical case of intussusception was reported in 1674 by Barbette of Am-sterdam. John Hunter documented its description in 17891, known as ‘intosusception’ at the time. Almost a century later, the first successful op-eration was performed on a child by Sir Jonathan Hutchinson2.
Adult intussusception constitutes less than 5% of intussusception cas-es3,4. Its incidence in resource-rich countries is 2–3 per 1,000,000 of the population per year5. There is a male to female ratio of 1.8:15. This ratio is debatable as some studies show fe-male dominance6,7. More recent re-views have paid less attention to the sex ratio3. It is the cause of 1%–3% of all cases of intestinal obstructions5,8, although a contrasting African se-ries ranked it as the fourth leading cause9, and accounts for less than
1% of hospital admissions10. There is a demonstrable cause in the major-ity of cases, usually an intraluminal neoplasm. Prominent reviews point to a 70%–90% existence of an un-derlying pathological cause4,5,8,11,12. These are mainly polyps and colonic malignancies. In contrast, childhood intussusception is a leading cause of intestinal obstruction. The treat-ment of the condition has always had some controversy. However, most au-thorities over the years have tended to agree on one common point—the treatment is surgical. This review discusses how to manage acute and chronic diseases in adult intussus-ception.
DiscussionThe authors have referenced some of their own studies in this re-view. These referenced studies have been conducted in accordance with the Declaration of Helsinki (1964) and the protocols of these studies have been approved by the relevant ethics committees related to the insti-tution in which they were performed. All human subjects, in these refer-enced studies, gave informed consent to participate in these studies.
PathophysiologyIntussusception is defined as the telescoping or invagination of one segment of gut into another. This is predominantly in a proximal to distal direction, the natural physiological peristaltic process. The mechanism for initiation of the invagination is not clear. It is postulated that any le-sion in the bowel wall or an irritant within its lumen may alter the normal peristaltic pattern and can trigger an
Department of Surgery, School of Medicine, Makerere College of Health Sciences, Makerere University, Kampala, Uganda
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For citation purposes: Ongom PA, Kijjambu SC. Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management. OA Emergency Medicine 2013 Aug 01;1(1):3.
Com
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invagination eventually leading to intussusception13. The portion of the gut propelled distally is known as the intussusceptum, with the distal (re-ceiving) portion being the intussus-cepiens (Figure 1).
Concerning the aetiology, intus-susception may be viewed in two contexts: a primary type and a sec-ondary type. Intussusceptions with no clear lead point are the primary or idiopathic type, present in 8%–20% of cases, and more likely to occur in the small intestines5,14,15. In contrast, the secondary type, constituting the greater majority, is due to an existing gut pathological lesion. This lesion is best described as a lead point: a func-tional or structural lesion associated with the intussusceptum16, postulat-ed to be the ‘trigger’ for intussuscep-tion14,17. The commonest ‘lead points’ are colonic malignant tumours, in up to 60% of the cases5. Benign tu-mours constitute the majority of the remaining 40%.
Figure 1: Schematic diagram il-lustrating the structure of an intus-susception. Longitudinal (top) and cross-sectional (bottom) diagrams illustrate a typical intussusception, with invagination of a segment of the gastrointestinal tract, intussuscep-tum (solid arrows), into an adjacent segment, intussuscepiens (open ar-rows). The mesentery (M) and mes-enteric vessels (arrowheads) follow the gut invagination.
Figure 2: (a) Ileocolic intussusception following resection without reduction. A typical finding at exploratory laparotomy for intussusception. The RED arrow is the ileum, while the BLUE arrow is the point of invagination; intususceptum–ileum, and the proximal part of the intussuscepiens (also ileum). The YELLOW arrow illustrates the ascending colon; distal end of intussuscepiens. (b) Ileocolic intussusception with strangulation. The intususcepiens (ascending colon) is opened to reveal the intussusceptum constituted of ileum that has undergone ischaemia and necrosis; strangulation. Haemorrhagic and dark areas indicate necrosis and the onset of gangrene
Following the initiation of invagi-nation, there is progressive propul-sion of the intussusceptum, with or without the lead point, in rhythm with the peristaltic wave of the gas-trointestinal tract. The intussuscep-tum carries along its mesentery. Due to the compromised space within the intussuscepiens, there is obstruction of the lumen of both the intussuscep-tum and intussuscepiens (Figure 2a). Accompanying this is the compro-mise of the mesenteric vascular flow to the intussusceptum: lymphatic, venous and arterial obstruction, in that order. The result is bowel ob-struction and inflammatory changes: oedema, thickening and ischaemia of the bowel wall. Continued peristal-sis will offset a vicious cycle of more oedema, obstruction and ischaemia, with subsequent accentuation of each of these with time. Gangrene may result (Figure 2b). Contempo-raneously with all these happenings are the classical pathophysiological manifestations of intestinal obstruc-tion: proximal distension, anatomical distortion, distal collapse and altered absorption and secretion.
LocationThe most common sites for intussus-ception are the junctions between freely moving segments and fixed (retroperitoneally or adhesionally) segments18, a mechanism favouring invagination. Intussusceptions have been classified according to their locations into four categories: (1) entero-enteric—involving the small intestines; (2) colo-colic—involving the large intestines; (3) ileo-colic—invagination of the terminal ileum into the ascending colon and (iv) ileo-caecal—the ileo-caecal valve being the lead point of the intussus-ceptum. The distinction between the ileo-colic and ileo-caecal forms is challenging12,13. Two other cat-egories may be included for clarity, though they are part of the colo-colic entity: (1) colo-rectal—colon invaginates through rectal ampulla and (2) recto-rectal—with rectum invaginating into the rectum but with no anal protrusion. Although there are cases of gastric involve-ment, this classification does not cover them.
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For citation purposes: Ongom PA, Kijjambu SC. Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management. OA Emergency Medicine 2013 Aug 01;1(1):3.
Com
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is arguably more recent literature in the form of case reports and case re-views. Table 2 presents a summary of some of the specific aetiologies for three selected review studies.
Clinical presentationThe clinical presentation of adult in-tussusception varies considerably. The presenting symptoms are often non-specific and the majority of cases have been reported as chronic, con-sistent with partial obstruction5,25. The classic triad of crampy abdomi-nal pain, bloody (‘currant jelly’) stool and a palpable mass of acute intus-susception in paediatric presentation is rare. The predominant symptoms are those associated with some form of bowel obstruction and most times still described non-specifically. These are abdominal pain and distension, nausea, vomiting, gastrointestinal bleeding, constipation and changes in bowel habits12,13. Three-quarters of patients (78%)5 present with
AetiologyThese can be benign, malignant or idiopathic causes. The aetiology also offers another form of classification and description of intussusceptions. A small intestinal intussusception is secondary either to the presence of luminal/intra-luminal or extra-luminal lesions (lead points). There are numerous specific lesions. The following have all been observed: inflammatory lesions, Meckel’s di-verticula, postoperative adhesions, lipomas, adenomatous polyps, lym-phomas, neurofibromas and sclero-derma. Reported iatrogenic causes have involved intestinal tubes19 and a patient with gastrojejunostomy20. For large intestines, benign tumours are more often adenomas, the most frequently occurring type (up to 26%)21, and lipomas.
Malignancy accounts for up to 30% of cases of intussusception occurring in the small intestines14. The specific types encountered are adenocarcino-ma, melanoma, lymphoma, sarcomas and squamous cell carcinoma3. On the other hand, from 60%6 to 65% of cases12,22 of intussusception occur-ring in the large bowel are more like-ly to have a malignant aetiology. One review differed by having 67% of all cases, the majority, being secondary to benign conditions23. However, this was a rather short 3-year review.
The more frequently reported types are adenocarcinoma, melanoma and lymphoma. Gastrointestinal stromal tumours (GISTs) have been reported in both small and large intestines. They were previously confused with leiomyomas, leiomyosarcomas and other mesenchymal tumours of the gut. This clinical entity is be-ing increasingly recognised since the advent of its definition over a dec-ade ago as specific tyrosine-protein kinase (KIT)-expressing mesenchy-mal tumours24. After the year 2000, there has been a marked rise in case reports of GISTs, a trend not seen in the past. Novel laboratory diagnos-tic techniques may account for their
Table 1 Reported cases of gastrointestinal stromal tumours (GISTs) as causes of intussusception between 2009 and 2012.Author (year) Case of GISTWilson et al. (2012) GIST presenting as gastroduodenal intussusception.Basir et al. (2012) Gastroduodenal intussusception as a first manifestation
of a gastric GISTSeok et al. (2012) Gastroduodenal intussusception due to pedunculated
polypoid GISTAkbulut et al. (2012) Ileocolic intussusception due to a GISTGyedu et al. (2011) GIST presenting acutely as gastroduodenal intussuscep-
tionGupta et al. (2011) GIST causing ileo-ileal intussusceptionAndrei et al. (2011) Intestinal intussusception due to ileal GISTWall et al. (2010) GIST presenting with duodenal-jejunal intussusceptionPirscoveanu et al. (2010) GIST in the caecum causing ileo-caecal-colic invaginationMenendez-Sanchez et al. (2009)
Gastrointestinal bleeding and intussusception due to GIST
Matek et al. (2009) GIST as a cause of the small intestine invaginationTheodoropoulos et al. (2009)
GIST causing small bowel intussusception in a patient with Crohn’s disease
Chan et al. (2009) Endo-laparoscopic reduction and resection of gastrodu-odenal intussuception of a GIST
increased identification. Reported cases between 2009 and 2012 are listed in Table 1.
There has never been a uniform perspective of classification of the aetiological factors involved in intus-susception. Study reviews conducted during the last 4 decades of the twen-tieth century tended to be centre-ori-ented and gave details of the specific aetiology for each case of intussus-ception. These reviews generally cov-ered periods of one to two decades. Even with the relatively small num-ber of cases, differing institutions show a wide range in variation of spe-cifics4,5,11,12. However, there are some uniform trends seen in most reviews. More recent reviews tend to offer a mixed picture, some give detail7, in-cluding comprehensive description11, while others have focused less on the percentages of particular aetiologies, taking into account the wide varia-tion in differential diagnoses3. There is little wonder, therefore, that there
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For citation purposes: Ongom PA, Kijjambu SC. Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management. OA Emergency Medicine 2013 Aug 01;1(1):3.
Com
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abdominal pain, nausea and vomit-ing. Pain is the commonest symp-tom, present in 90% of the patients7. Nausea and vomiting come next in line, though with varying frequen-cies. Fever, weight loss, constipation and diarrhoea are infrequent. A pal-pable abdominal mass is present in less than 10% of the patients. Bloody stool is seen only in one-quarter of the patients5. Dance’s sign (apparent right iliac fossa ‘emptiness’) is only occasionally appreciable. Overall, the symptoms and signs of acute in-testinal obstruction are present only in one-half of the patients. The other half presents with chronic symptoms (non-emergencies) over a period from weeks to months.
Table 2 Aetiological lesions causing adult intussusception from three selected review studies spanning three decades
MalignantAdenocarcinoma 58.3 2.3 42.3 18.2Leiomyosarcoma 8.3 4.2 4.5Melanoma 8.3 29.5 9.1Lymphoma 6.8 4.5Metastases 12.5 9.1Some aetiologies are not classified.
The clinical features also have an association with the underlying pathological lesion’s nature and site, and the presence or absence of a lead point. A transient non-obstruct-ing intussusception without a lead point is frequently idiopathic and, in the past, has been described as occasionally spontaneously resolv-ing without any specific treatment. Contrastingly, intussusception with an organic lesion as the lead point usually presents as a bowel obstruc-tion, acute, persistent or relapsing. Patients with benign enteric lesions have been said to have a higher fre-quency of nausea, vomiting and abdominal pain. Those with colonic malignancies tend to present more
with bloody or melaena stools5. This may plausibly be explained by the pathophysiological disruption due to location and character of the tu-mour type. The mean duration of symptoms appears not to be of clini-cally practicable value, considering the variation in symptomatology. The symptom duration range has been reported to be between 1 and 365 days, or even longer. The mean duration of symptoms is commonly observed as being longer in benign as compared with malignant lesions, and in enteric as compared with colonic lesions. Pinpoint details of means, medians and modes for be-nign enteric versus colonic and ma-lignant enteric versus colonic are not covered by previous reviews.
Investigations For DiagnosisImagingAdult intussusception is one of those conditions that may be difficult to di-agnose with a good degree of confi-dence based on the clinical features alone. Moreover, there is variation in the imaging characteristics too. Matching the clinical presentation and imaging characteristics to make a preoperative diagnosis is challeng-ing. Accurate preoperative diagnoses have been reported at rates as low as 40.7%6 and 50%26. Plain abdominal films are commonly the first inves-tigation, considering that obstruc-tive symptoms dominate the clinical picture in most patients. The com-mon signs of intestinal obstruction are usually demonstrated, providing information regarding the site of ob-struction7,27: multiple air fluid levels and a ‘questionable’ mass7. Upper gastrointestinal contrast series (Ta-ble 3) may show a ‘stacked coin’ (Fig-ure 3a) or ‘coil-spring’ (Figure 3b) sign, while a barium enema examina-tion, useful in colo-colic or ileo-colic intussusception, may show a ‘cup-shaped’ filling defect, or ‘spiral’ or ‘coil-spring’ signs6,7.
Ultrasonography is a useful in-vestigation for the diagnosis of
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For citation purposes: Ongom PA, Kijjambu SC. Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management. OA Emergency Medicine 2013 Aug 01;1(1):3.
Com
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.Figure 3: Contrast radiological appearance of intussuscepted intestines. (a) This demonstrates the ‘Stacked coin’ sign. (b) This demonstrates the ‘Coiled spring’ sign.
view29. This procedure and its in-terpretation require good operator knowledge and skill. However, obesi-ty and the presence of large amounts of air in the distended bowel loops limit the image quality and the sub-sequent diagnostic accuracy.
Abdominal computed tomography (CT) is currently considered as the most sensitive radiological method to confirm intussusception, with a reported diagnostic accuracy ranging from 58% to 100%5,30. The character-istic features include a heterogene-ous ‘target’ (Figure 5a) or ‘sausage-shaped’ (Figure 5b) soft-tissue mass with a layering effect (Figure 5c; Table 4). Mesenteric vessels within the bowel lumen are also typical13. A CT scan may define the location and nature of the mass, its relation-ship to surrounding tissues and may contribute to staging of a tumour for a suspected malignant cause7. It facilitates distinguishing between intussusception without a lead point from that with a lead point31. In most cases, radiologists can readily make the correct diagnosis. However, it is broadly agreed that these CT findings that help differentiate between lead point and non-lead point intussus-ception have a considerable degree of overlap32. It is accepted that when a lead mass is seen at CT as a sepa-rate and distinct entity in contrast to oedematous bowel, it can be con-sidered a reliable indicator of a lead point intussusception. Differentiat-ing between lead point and non-lead point intussusception is important in determining the appropriate treat-ment and has the potential to reduce the prevalence of unnecessary surgi-cal interventions.
Decision-making using radio-logical findings remains a balancing act32. In a study with 15 patients, 7 Patients were operated on with diagnoses of intussusception based on imaging findings. The remaining eight patients had their diagnoses made at operation. Different imaging modalities were used32. Zubaidi et al.
Figure 4: Ultrasonographic appearance of intussuscepted intestine. (a) This illustrates the classic ‘Target’ or ‘Doughnut’ sign; transverse view. (b) This illustrates the ‘Pseudo-Kidney/sign; longitudinal view.
intussusception, both in children and in adults28,29. In many centres, it is the standard investigation. The classical imaging features (Table 3) include
the ‘target’ (Figure 4a) or ‘doughnut’ signs in the transverse view, and the ‘pseudo-kidney’ (Figure 4b) sign or ‘hay-fork’ sign in the longitudinal
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For citation purposes: Ongom PA, Kijjambu SC. Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management. OA Emergency Medicine 2013 Aug 01;1(1):3.
Com
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Figure 5: Contrast–enhanced CT scan of the abdomen showing intussusception of small intestines. Illustrated are classic ‘Target’ sign (arrow in a), and the ‘Sausage-shaped’ mass (arrow in b) mass. These signs are considered pathognomonic for intussusception. (c) Contrast-enhanced CT scan of the abdomen showing small gut intussusception. Illustrated is the typical multilayered appearance of an intussusception. The intussusceptum (black arrowhead), with accompanying mesenteric fat and blood vessels (arrow), is surrounded by the thick-walled intussuscepiens (white arrowhead).
Table 4 CT features distinguishing between lead point and non-lead point intussusceptionLead point intussusception• Signs of bowel obstruction• Bowel wall oedema• Loss of the classic three-layer appearance• Demonstration of the lead massNon-lead point intussusception• No signs of proximal bowel obstruction• Target-like mass• Sausage-shaped mass• Layering effect
intervention because of the large proportion of structural anomalies and the high incidence of malignan-cies. However, the extent of bowel resection and manipulation of the in-tussuscepted bowel during reduction remains controversial14. In contrast to paediatric patients, preoperative reduction with barium or air is not a definite treatment for adult intus-susception6,14, except a few adoles-cent cases. There are potential risks associated with preliminary manipu-lation and reduction of an intussus-ception; (1) intraluminal tumour seeding, (2) venous tumour dissemi-nation, (3) gut perforation with peri-toneal seeding of microbes and tu-mour cells and (4) increased risk of anastomotic complications of the fri-able and oedematous bowel, in case of resection and anastomosis7,8,13,14,26. Some authors argue that reduction should not be attempted if there are signs of inflammation or ischaemia of the bowel wall30.
Therefore, in patients with ileo-colic, ileo-caecal and colo-colic in-tussusceptions, especially those over 60 years of age, formal resections (open or laparoscopic) using ap-propriate oncological principles are recommended as there is a high inci-dence of malignancy as the underly-ing aetiology. Primary anastomosis between healthy and viable tissue is done6,12,14,26. For right-sided colonic intussusceptions, resection and pri-mary anastomosis can be carried out even in unprepared bowel5, while for left-sided or rectosigmoid cases resec-tion with construction of a colostomy or a Hartmann’s procedure, and sec-ondary anastomosis is recommended especially in the emergency setting. However, when a preoperative di-agnosis of a benign lesion is safely established, the surgeon may reduce the intussusception by milking it out in a distal to proximal direction36, al-lowing for a limited resection. Often, chronic intussusception does not al-low for successful manual reduction to be performed, due to thickening,
reported an even lower preoperative diagnosis frequency of 14%7. Specif-ics of the imaging modalities were not available.
Endoscopic diagnosisFlexible endoscopy of the lower gas-trointestinal tract is very valuable in evaluating the cases of intussus-ception presenting with subacute or chronic large bowel obstruction14. Its main benefits are confirmation of the intussusception (Figure 6), its localisation, demonstration of the underlying organic lesion serving as a lead point and possible treat-ment. Snare polypectomy has been used to treat polypoid causes, though it is considered unsafe for chronic
intussusception considering the background of chronic tissue ischae-mia and possible necrosis of the in-tussuscepted bowel segment’s wall33. However, it has limited use for large lead points such as ‘giant’ lipomas34. Lipomas offer characteristic colono-scopic features (Table 5). Colonos-copy has been successfully used to reduce intussusception35.
TreatmentBecause adults present with acute, subacute or chronic non-specific symptoms22, the initial diagnosis is often missed or delayed and is then established at surgery (Figure 7). Most surgeons agree that adult intussusception requires surgical
Page 7 of 11
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For citation purposes: Ongom PA, Kijjambu SC. Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management. OA Emergency Medicine 2013 Aug 01;1(1):3.
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Figure 6: Colonoscopic view of intussusception. Illustrated are the intussusceptum (blue arrow) and intussuscepiens (yellow arrow).
the general status of the patients and sufficient laparoscopic expertise of the surgeon. Laparoscopic-assisted surgery is also used in suitable cas-es39. This involves laparoscopic ex-ploration first for diagnosis (Figure 9), followed by an easier definite re-section procedure39.
There is ongoing debate on when to use endoscopy or laparoscopy, es-pecially for lipoma lead points. Many surgeons manage patients with small asymptomatic colonic lipomas with regular follow up. For those that are large (diameter >2 cm) and/or symp-tomatic, resection is considered, although the choice between endo-scopic or surgical resection (open or laparoscopic) remains debatable. Li-pomas even >2 cm have been safely removed by endoscopic resection. When surgery is indicated, the prac-tice is tending towards laparoscopy as the ideal approach in all patients for whom minimally invasive surgery is not contraindicated40. Favourable outcomes have also been noted with adenomas.
ConclusionIntussusception in adults is an in-frequent problem. Nevertheless, it is a challenging condition that re-quires the surgeon to understand its epidemiology, anomalous clinical presentation and treatment options. Diagnosis can be puzzling because of non-specific and often subacute symptoms with no out right pathog-nomonic clinical signs.
A strong pillar towards correct management is having a high index of suspicion. The continuously in-creasing variety of possible aetio-logical lesions, evidenced by the high case report numbers, means we can never be sure of the pathology for the next case till after surgery. There is no ‘gold standard’ diagnostic test and many cases are diagnosed at laparotomy.
Treatment usually requires re-section of the involved bowel seg-ment. Reduction can be attempted
Table 5 Colonoscopic features of lipomas, frequent colonic intussusception lead pointsFeature Manoeuvre eliciting featureSmooth surface Regular and continuous on observation‘Cushion sign’ or ‘Pillow sign’
Exertion of pressure with forceps against the lesion results in depression of the mass
‘Naked fat sign’ Extrusion of fat while performing a biopsy
fibrosis and cross-scarring within the intussusceptum36 (Figure 8).
Enteric intussusceptions due to benign lesions require only reduc-tion and limited resection37. Reduc-tion alone is adequate for idiopathic forms provided the bowel appears non-ischaemic and viable5. Some patients at risk of a short bowel syn-drome require special consideration. Two typical scenarios demonstrate this:
1. Multiple small intestinal pol-yps causing intussusception, as in Peutz-Jeghers syndrome—a
combined approach of limited intestinal resections and multi-ple snare polypectomies should be done38.
2. Intussusception involving al-most the entire colon and sig-nificant ileal length—‘milking’ a substantial length, then resec-tion of what is irreducible36.
Several reports have described the laparoscopic approach to treatment of adult intussusception for various lesions of both small and large bowel (Table 6). It has been used success-fully in selected cases, depending on
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Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Ongom PA, Kijjambu SC. Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management. OA Emergency Medicine 2013 Aug 01;1(1):3.
Com
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. Al
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Figure 7: Ileocolic intussusception found at laparotomy. The yellow arrow points to ileum at the point of invagination into the caecum/ascending colon and the red arrow points to the intussuscepiens containing intussusceptum. The green arrow illustrates mesentery. Deep blue arrow points to an enlarged lymph node within the mesentery.
Figure 8: Chronic ileo-caeco-colic intussusception; the affected gut has been resected. Green arrow – lead point of the intussusceptum. Yellow arrow – ischaemic changes over the intussusceptum. Red arrow – haemorrhagic areas. The intussusceptum was only partially reducible. Histology showed chronic fibrosis and ischaemic changes, but no gangrene. This intussusceptum had protruded per anus. There was no tumour.
in small-bowel intussusception if the segment involved is viable or malignancy is not suspected. A more careful approach is recommended in colonic intussusception because of a significantly higher chance of ma-lignancy. This entire critical review process has enabled us to propose a diagnostic and treatment guiding al-gorithm (Figure 10).
References1. Noble I, Master surgeon: John Hunter. New York: J. Messner; 1971.p185.2. Hutchinson H, Hutchinson J. Jonathan Hutchinson, life and letters. London: W. Heinemann Medical Books; 1946.3. Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, et al. Intussusception of the bowel in adults: a review. World J Gastroenterol. 2009 Jan;15(4):407–11.4. Agha FP. Intussusception in adults. AJR Am J Roentgenol. 1986 Mar;146(3):527–31.5. Azar T, Berger DL. Adult intussuscep-tion. Ann Surg. 1997 Aug;226(2):134–8.6. Eisen LK, Cunningham JD, Aufses AH Jr. Intussusception in adults: insti-tutional review. J Am Coll Surg. 1999 Apr;188(4):390–5.7. Zubaidi A, Al-Saif F, Silverman R. Adult intussusception: a retrospec-tive review. Dis Colon Rectum. 2006 Oct;49(10):1546–51.8. Croome KP, Colquhoun PH. Intus-susception in adults. Can J Surg. 2007 Dec;50(6):E13–4.9. Lawal OO, Olayinka OS, Bankole JO. Spectrum of causes of intestinal obstruc-tion in adult Nigerian patients. S Afr J Surg. 2005 May;43(2):34, 36.10. Ochiai H, Ohishi T, Seki S, Tokuyama J, Osumi K, Urakami H, et al. Prolapse of intussusception through the anus as a result of sigmoid colon cancer. Case Rep Gastroenterol. 2010 Sep;4(3):346–50.11. Wang N, Cui XY, Liu Y, Long J, Xu YH, Guo RX, Guo KJ. Adult intussusception: a retrospective review of 41 cases. World J Gastroenterol. 2009 Jul;15(26):3303–8.12. Nagorney DM, Sarr MG, Mcll-rath DC. Surgical management of
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Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Ongom PA, Kijjambu SC. Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management. OA Emergency Medicine 2013 Aug 01;1(1):3.
Com
petin
g in
tere
sts:
non
e de
clar
ed. C
onfli
ct o
f int
eres
ts: n
one
decl
ared
. Al
l aut
hors
con
trib
uted
to c
once
ption
and
des
ign,
man
uscr
ipt p
repa
ratio
n, re
ad a
nd a
ppro
ved
the
final
man
uscr
ipt.
All a
utho
rs a
bide
by
the
Asso
ciati
on fo
r Med
ical
Eth
ics (
AME)
eth
ical
rule
s of d
isclo
sure
. intussusception in the adult. Ann Surg. 1981 Feb;193(2):230–6.13. Weilbaecher D, Bolin JA, Hearn D, Ogden W 2nd. Intussusception in adults. Review of 160 cases. Am J Surg. 1971 May;121(5):531–5.14. Begos DG, Sandor A, Modlin IM. The diagnosis and management of adult intussusception. Am J Surg. 1997 Feb;173(2):88–94.15. Erkan N, Haciyanli M, Yildirim M, Sayhan H, Vardar E, Polat AF. Intus-susception in adults: an unusual and challenging condition for surgeons. Int J Colorectal Dis. 2005 Sep;20(5): 452–6.16. Chen R, Zhao H, Sang X, Mao Y, Lu X, Yang Y. Severe adult ileosigmoid intus-susception prolapsing from the rectum: a case report. Cases J. 2008 Sep;1(1): 198.17. Takeuchi K, Tsuzuki Y, Ando T, Seki-hara M, Hara T, Kori T, et al. The diagnosis and treatment of adult intussusception. J Clin Gastroenterol. 2003 Jan;36(1): 18–21.
Table 6 Documented laparoscopic and laparoscopically assisted surgeries for intussusception done in recent years. Each case experience is particularly uniqueAuthor (Year) ProcedureSon et al. (2013) Laparoscopic surgery for an intussusception caused by a lipoma in the ascending colon.Rose et al. (2012) Laparoscopic longitudinal jejunectomy for intussusception after gastric bypass.Kim et al. (2012) Laparoscopic colectomy of colonic intussusceptions in adultsBasterra et al. (2011) Laparoscopic management for giant lipoma-induced colonic intussusception. Lucas et al. (2010) Laparoscopic resection of a small bowel lipoma with incidental intussusception.Ho et al. (2010) Post-colonoscopy colonic intussusception reduced via a laparoscopic approach.Greenley et al. (2010) Laparoscopic management of sigmoidorectal intussusception.Harvey et al. (2010) Laparoscopic resection of metastatic mucosal melanoma causing jejunal intussusception.Lin et al. (2007) Laparoscopy-assisted resection of ileoileal intussusception caused by intestinal lipoma.Palanivelu et al. (2007)
Minimal access surgery for adult intussusception with subacute intestinal obstruction: a single cen-tre’s decade long experience.
Chuang et al. (2007) Laparoscopic management of sigmoid colon intussusception caused by a malignant tumorIshibashi et al. (2007) Laparoscopic resection for malignant lymphoma of the ileum causing ileocecal intussusception.Akatsu et al. (2007) Adult colonic intussusception caused by caecum adenoma: successful treatment by emergency laparoscopyMcKay et al. (2006) Ileocecal intussusception in an adult: the laparoscopic approachWu et al. (2006) Laparoscopic diagnosis and treatment of small bowel obstruction caused by postoperative intussus-
ceptionPark et al. (2006) Sigmoidorectal intussusception of sigmoid colon adenoma treated by laparoscopic anterior resection
after sponge-on-the-stick-assisted manual reductionJelenc et al. (2005) Laparoscopically assisted resection of an ascending colon lipoma causing intermittent intussusception.
Figure 9: Laparoscopic view if small intestinal intussusception. Illustrated is a typical invagination of an intussusceptum into an intussuscepiens.
Page 10 of 11
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Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)
For citation purposes: Ongom PA, Kijjambu SC. Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management. OA Emergency Medicine 2013 Aug 01;1(1):3.
Com
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Figure 10: Basic algorithm for diagnosis and treatment of adult intussusception.
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Intestinal invagination in adults: preop-erative diagnosis and management. Int J Colorectal Dis. 2004 Jan;19(1):68–72.26. Reijnen HA, Joosten HJ, de Boer HH. Diagnosis and treatment of adult intus-susception. Am J Surg. 1989 Jul;158(1): 25–8.27. Cerro P, Magrini L, Porcari P, De Angelis O. Sonographic diagnosis of intussusceptions in adults. Abdom Imag-ing. 2000 Jan–Feb;25(1):45–7.28. Fujii Y, Taniguchi N, Itoh K. Intussus-ception induced by villous tumor of the colon: sonographic findings. J Clin Ultra-sound. 2002 Jan;30(1):48–51.29. Boyle MJ, Arkell LJ, Williams JT. Ul-trasonic diagnosis of adult intussuscep-tion. Am J Gastroenterol. 1993 Apr;88(4): 617–8.
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For citation purposes: Ongom PA, Kijjambu SC. Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management. OA Emergency Medicine 2013 Aug 01;1(1):3.
Com
petin
g in
tere
sts:
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ts: n
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