In several reports, approximately 50% of malignant lesions causing small bowel intussusception were metastatic (miliary) melanomas.8 Malignant intraluminal causes of small bowel intussusception include primary leiomyosarcomas, adenocarcinoma, GIST tumors, carcinoid tumors, neuroendocrine tumors, and lymphomas. The classic feature is the target or doughnut sign caused by the edematous intussuscipiens forming an external ring around the centrally based intussusceptum.25 On the transverse view, the pseudo-kidney appearance is formed by the layers of the intussusception. The presenting symptoms in adult patients with intussusception are non-specific and often long standing. (Images courtesy of Dr. Nancy McNulty, MD.). The result is bowel obstruction and inflammatory bowel changes ranging from thickening to ischemia of the intestine wall (21). Predictive factors of malignancy in adults with intussusception. In contrast to children, where intussusception is benign, preoperative reduction with barium or air is not recommended for adults. Additionally, decreased reliability was noted due to air levels in the bowel, a large amount of feces in the colon and malrotation. Interestingly, the reported diagnostic accuracy of CT is 58%100% (29). Presentation often includes colicky abdominal pain, flexing of the legs, fever, lethargy, and vomiting, with blood in the stool in some cases. Part of a proximal segment of the bowel slides into the next distal section. ti.liamtoh@niodraccir, Corresponding author: Riccardo Inchingolo, MD, Chief Doctor, Director, Interventional Radiology Unit, "F. Miulli" General Regional Hospital, Via di Santeramo, Acquaviva delle Fonti 70021, Bari, Italy. Similarly, Guilln Paredes et al found that despite the fact that ultrasound was used more frequently, it did not guarantee a diagnosis on most occasions and abdominal CT was recommended. Pneumoperitoneum is then established, and two additional 5-mm ports are placed, one in the left lower quadrant and the other suprapubically (in the case of enteroenteric or ileocolic intussusception). All the researchers agree that for adult intussusception laparotomy is the treatment of choice rather than attempts at hydrostatic reduction in view of the high incidence of underlying malignancy (32). It is the most common abdominal emergency in early childhood, particularly in children younger than two years of age [ 1 ]. Ileocolic intussusception is the most common form of intussusception in children. On the other hand, intussusception is a surgical emergency associated to high rates of mortality in case of delayed treatment, therefore it is important to think about this less common diagnostic possibility when facing an acute abdominal pain with sign of bowel obstruction. In our study, 74% of the patients had abdominal pain, and the incidence of haemafecia, nausea and . The diagnosis and treatment of adult intussusception. Before In: StatPearls [Internet]. 22 Onkendi EO, Grotz TE, Murray JA, Donohue JH. In adults, it typically represents obstruction from a potentially malignant etiology. Chand M, Bradford L, Nash GF. Historically, adult intussusceptions have been treated surgically due to the association of pathology serving as lead point. Intussusception results from the alteration of normal peristalsis by a lesion in the bowel wall that creates invagination. Barium studies are contraindicated if there is a possibility of bowel perforation or ischemia due to the risk of barium peritonitis. Colonoscopy is another useful tool in evaluating intussusception, notably when the presenting symptoms include a large bowel obstruction; it allows the lesion to be diagnosed and biopsied. An abdominal CT scan may define the location, the nature of the mass, its relationship to surrounding tissues and, moreover, it may help staging the patient with suspected malignancy causing the intussusception. It is recommended to sample suspected fluid collections for culture as well as to biopsy suspected lesions. Similar to infectious causes, hypertrophy of Peyer patches and/or mesenteric lymphadenopathy can act as a lead point. Therefore, intussusceptions in children are idiopathic in 90% of cases and can safely be reduced. Additional imaging modalities can also have benefit in the evaluation of intussusception. Anyway, the increased use of cross sectional imaging has increased the early-diagnosis of intussusception, in many cases with a successful nonoperative management; such findings led to some questioning about the optimal management of these conditions. Boyle MJ, Arkell LJ, Williams JT. Department of Endoscopy, "Madonna delle Grazie" Hospital, Matera 75100, Italy, Department of Surgery, "Madonna delle Grazie" Hospital, Matera 75100, Italy, Department of Radiology, "Madonna delle Grazie" Hospital, Matera 75100, Italy, Digestive Endoscopy Unit, Hopital Prive Armand Brillard, Nogent-sur-Marne 94130, France, Interventional Radiology Unit, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Bari, Italy, Department of Radiology, Santa Casa de Campo Grande, Campo Grande 79010-050, Brazil, Interventional Radiology Unit, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Bari, Italy. Shortly after the onset of pain, vomiting may occur. The choice of using a laparoscopic or open procedure depends on the clinical condition of the patient and especially on the surgeons advanced laparoscopic experience (4043). The site is secure. The patient present abdominal tenderness and signs of systemic inflammatory response syndrome (i.e., hypothermia or hyperthermia, hypotension, and tachycardia). The development of intussusception may thus result from the invagination of the muscular ileocecal valve into the cecum due to the decreased rigidity of the cecal wall caused by the paucity of developed taeniae coli. It is reported in literature that the first to operate on a child with intussusception was Sir Jonathan Hutchinson in 1871 (3, 4). The attempt of hydrostatic reduction in the adult population is not indicated; on the contrary, in the pediatric population this is the treatment of choice in the majority of cases; in fact, in this latter group of age the percentage of surgical treatment is so far less the 10% of the reported cases[22]. Intussusception can also be caused by noninfectious etiologies, such as intestinal allergies, Celiac disease, and Crohn disease. Adult intussusception: case reports and review of literature. sharing sensitive information, make sure youre on a federal Bar-Ziv J, Solomon A. Computed tomography in adult intussusception. In pediatric patients with cystic fibrosis, foreign bodies, intestinal parasites, and inspissated feces may result in lead points in the ileum causing ileocolic intussusception. Guest Editor: Jason S. Mizell, MD, FACS, FASCRS, intussusception, intussusceptum, intussuscipiens, bowel obstruction. Adult intestinal intussusception: CT appearances and identification of a causative lead point. With early diagnosis, appropriate. Diagnosis of intussusception in adult is challenging since the acute abdominal pain is at the same time a non-specific symptom and one of the most frequent complaint reported in the setting of emergency medicine. Interestingly, coloanal intussusceptions are rare and occur in the setting of a benign or malignant tumour, with 50% attributable to a malignant lesion. 14 Federal government websites often end in .gov or .mil. and transmitted securely. The site is secure. In either case, quick, less invasive, and less costly approaches are initially employed in the making of the diagnosis. Symptoms include abdominal pain, which may wax and wane, vomiting, bloating, and bloody stool. In these setting, preoperative endoscopy can be done in order to confirm the presence of pathology and/or cancer[8]. In non emergency patients the diagnosis can be very challenging. McKay R. Ileocecal intussusception in an adult: the laparoscopic approach. Intussusception, more common in the small bowel and rarely involving only the large bowel, has historically presented as small bowel obstruction, although there is an increasing appreciation of cases of transient, asymptomatic intussusception within the era of abdominal CT scans. Cerro P, Magrini L, Porcari P, De Angelis O. Sonographic diagnosis of intussusceptions in adults. government site. http://creativecommons.org/Licenses/by-nc/4.0/, Adherences, coeliac disease, Crohns disease, endometriosis, hamartoma, infections, Kaposi sarcoma, lipoma, Meckel diverticulum, neurofibroma, polyps (inflammatory, adenomatous), stromal tumor, tubercolosis, Adenocarcinoma, carcinoid tumors, leiomyosarcoma, lymphoma, malignant gastrointestinal stromal tumor, metastatic carcinoma, neuroendocrine tumor, Adherences, inflammatory pseudopolyp, lipoma, polyps (inflammatory, adenomatous), Adenocarcinoma, metastatic carcinoma, lymphoma, gastrointestinal stromal tumor. This condition is believed that accounts for less than 0.1% of all adult hospital admissions (7). As nonoperative reduction is a common practice for pediatric intussusception, practitioners should be aware of the possibility of Waugh syndrome. If needed, other ports can be placed depending on the location of the pathology. Akcay MN, Polat M, Cadirci M, Gencer B. Tumor-induced ileo-ileal invagination in adults. In addition, all the researchers report that, due to a significant risk of associated malignancy, radiologic decompression is not recommended preoperatively in adults (10). Accessibility Ileocolic intussusception, the most common type in children, requires reduction by ultrasound-guided or fluoroscopic pneumatic or hydrostatic enema, and is successful in 85 to 90% of cases.28 Close observation is required due to the heightened possibility of recurrence within the first 24 hours. This telescoping action often blocks food or fluid from passing through. Additionally, altered peristalsis in focal areas of the bowel wall leading to aperistaltic segments that feed into peristaltic areas, as in the submucosal hemorrhages in Henoch-Schonelin purpura, allows for the formation of an intussusceptum. The optimal management for adult intussusception is still controversial, nevertheless its definitive treatment consists in surgical intervention with appropriate approach depending on the underlying etiology and location. Typical are also considered mesenteric vessels within the intestinal lumen (30). In the United States, about 35 to 40 of every 100,000 babies younger than age 1 is hospitalized for intussusception. The clinical presentation of intussusception in adults can be nonspecific, with the "classic" triad of abdominal pain, vomiting, and currant-jelly stools found in children rarely seen, leading to delays in diagnosis. Assunta Biscaglia, Department of Radiology, "Madonna delle Grazie" Hospital, Matera 75100, Italy. [1][2][3][4] Most adult intussusception patients often experience intermittent abdominal pain and vomiting. Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, Theodosopoulos T. Intussusception of the bowel in adults: a review. [1] Intussusception occurs more commonly in children than adults. Review of 160 cases. For laparoscopic cases, we utilize a 4-cm periumbilical question-mark-shaped initial incision, with a small wound protector; this incision will ultimately be used for specimen extraction and for construction of the extracorporeal anastomosis. As a library, NLM provides access to scientific literature. The .gov means its official. The reported drawbacks of this method is that malignant cells may be disseminated during the attempt. Malignant and benign neoplasms account for 60% of cases with a lead point; the remaining non-idiopathic cases are usually caused by postoperative adherences, Crohns disease, infections, intestinal ulcers, and Meckel diverticulum[7,11]. Several key clinical conditions and findings on imaging can assist the surgeon faced with adult intussusception to confidently proceed with surgical exploration: (1) intussusception with associated signs or symptoms of clinical obstruction, (2) intussusception with a lead point mass appreciated on cross-sectional imaging studies, and (3) colocolonic or ileocolic intussusception given the high association with malignancy in many of these cases, particularly ileocolic. As the ascending colon is not fixed to the retroperitoneum, the intussusceptum often advances into the descending colon and rectum without compromising the vascularity of the bowel. All the researchers report that surgery is the definitive treatment of adult intussusceptions (13). [2] In adults, surgical removal of part of the bowel is more often required. Takeuchi K, Tsuzuki Y, Ando T, et al. In addition, most surgeons agree that adult intussusception requires surgical resection because the majority of patients have intraluminal lesions. official website and that any information you provide is encrypted The compromised blood flow to the affected segment can cause necrosis of the intestinal wall with bacterial translocation, peritonitis, sepsis and even perforation. Laboratory values typically reveal an elevated white blood cell count and nonspecific inflammatory markers/acute phase reactants such as thrombocytosis and elevated C-reactive protein.20 Preoperative diagnosis is often missed or delayed because of non-specific symptoms. 32 This has created some degree of controversy regarding optimal management of these patients. Adult intestinal intussusception: CT appearances and identification of a causative lead point. McKay R. Ileocecal intussusception in an adult: the laparoscopic approach. and transmitted securely. Intussusception usually involves the small bowel and rarely the large bowel. Voore N, Weisner L. Unusual cause of intussusception. Undoubtedly, this procedure requires an appropriate interpretation by an experienced radiologist, in order to establish the diagnosis of intussusception. A standardized laparoscopic technique to approach intussusception is not available, due to the all different possible causes and locations, some tips and tricks are reported in literature[8,32,33]: the pneumoperitoneum establishment must be performed with open laparoscopy at the umbellicum because of the high risk of bowel lesions with the Verres technique. Small bowel is more often involved by intussusception rather than large bowel. [1] In children, males are more often affected than females. 10 Independent predictors of malignancy include colonic intussusception and anemia (hemoglobin <12 g/dL). Barussaud M, Regenet N, Briennon X, de Kerviler B, Pessaux P, Kohneh-Sharhi N, Lehur PA, Hamy A, Leborgne J, le Neel JC, Mirallie E. Clinical spectrum and surgical approach of adult intussusceptions: a multicentric study. Abbreviation: GI, gastrointestinal tract. Fujii Y, Taniguchi N, Itoh K. Intussusception induced by villous tumor of the colon: sonographic findings. Fever is usually a sign of the onset of intestinal necrosis. Wang LT, Wu CC, Yu JC, Hsiao CW, Hsu CC, Jao SW. Clinical entity and treatment strategies for adult intussusceptions: 20 years' experience. 8 Courtesy of Daniel P. Croitoru, MD. Inflammatory fibroid polyp (IFP) is one of the rarest benign tumors of the gastrointestinal tract. Color Doppler may be used to demonstrate decreased blood flow to the intussusceptum if bowel is ischemic. Intussusception is an invagination of the bowel lumen with the invaginated portion (the intussusceptum) passing distally into the ensheathing outer portion (the intussuscipiens) via peristalsis. Treasure Island (FL): StatPearls Publishing; 2021. Adult intussusception - 14 case reports and their outcomes. On the other hand, intussusception with an organic lesion as the lead point usually presents with the clinical picture of bowel obstruction (15, 16). Eisen LK, Cunningham JD, Aufses AH., Jr Intussusception in adults: institutional review. government site. Rea J D, Lockhart M E, Yarbrough D E, Leeth R R, Bledsoe S E, Clements R H. Approach to management of intussusception in adults: a new paradigm in the computed tomography era. Surgical management of intussusception in the adult. Boudiaf M, Soyer P, Terem C, Pelage JP, Maissiat E, Rymer R. Ct evaluation of small bowel obstruction. [1] Signs and symptoms Inflammatory fibroid polyp of the small intestine. Intestinal intussusception presents considerable variability in the patient's clinical presentation (abdominal pain, vomiting, nausea) and shows signs of palpable abdominal masses on objective examination. Bethesda, MD 20894, Web Policies Before Ileocolic intussusception in adults is a unique variant in which nearly 100% of cases have a malignant lead point, namely, cecal adenocarcinoma involving the ileocecal valve.9. Careers, Unable to load your collection due to an error. Thus, no clear evidence exists on this issue. Intussusception is defined as prolapse of a proximal bowel segment into a distal segment. Intussusception is defined as invagination of one segment of the bowel into an immediately adjacent segment. 19 Recently, Ciftci found in a small study of six patients that CT was ideal for the diagnosis of intussusception.26 In that same study, ultrasound was found to be of less utility in diagnosing intussusception. In this review, we discuss the symptoms, location, etiology, characteristics, diagnostic methods and treatment strategies of this rare and enigmatic clinical entity in adult. Abdominal mass is noted in 24% to 42% of cases. Summary. Intussusception, more common occur in the small bowel and rarely involve only the large bowel. Zubaidi A, Al-Saif F, Silverman R. Adult intussusception: a retrospective review. Surgeons must therefore be familiar with the epidemiology, etiology, diagnosis, and treatment of both pediatric and adult intussusception. The most important characteristic of pain is its periodic, intermittent nature, which makes the diagnosis elusive. Reijnen HA, Joosten HJ, De Boer HH. Carlos Alberto Pratic, Digestive Endoscopy Unit, Hopital Prive Armand Brillard, Nogent-sur-Marne 94130, France. Another transient phenomenon is the inverted appendix, which, after ruling out mass lesion by cross-sectional imaging, can often be observed. Ultrasonic diagnosis of adult intussusception. Other authors suggest that surgical resection without reduction should be the standard treatment in adults, as about 50% of colonic and enteric adult intussusceptions are associated with malignant lesions. Part of a proximal segment of the bowel slides into the next distal section. Zubaidi A, Al-Saif F, Silverman R. Adult intussusception: a retrospective review.
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