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Intussusception in children is the most common cause of bowel obstruction of that age. In contrast, its appearance in adults only accounts for ~5% of all cases of intussusception and 1-5% of patients with intestinal obstruction[1, 2].
- In intussusception part of the gastrointestinal (GI) tract invaginates or telescopes into another neighbouring portion.
- There is usually a 'lead point' which is the cause of the invagination.
- Cases in adults can be described as:
- Ileo-ileal (or entero-enteric - affecting only the small bowel).
- Colo-colic (affecting only the large bowel).
- Ileo-colic (small bowel is pushed into the large bowel).
- Ileo-caecal (small bowel is pushed into the caecum).
- Ileo-ileal intussusceptions are more common than ileo-colic intussusceptions.
- A cause is identified in up to 90% of cases and includes the following:
- Malignancy in 54-69% (primary neoplasms - eg, bowel carcinoma, lymphomas, polyps, or lipomas or metastatic deposits (rare) - eg, renal cell carcinoma).
- Meckel's diverticulum.
- Abnormal peristalsis (secondary to ulceration).
- Heterotopic pancreatic tissue.
- Inflammatory bowel disease.
- Association with enterovirus infection.
- Association with diabetic ketoacidosis - possibly by altering GI tract motility.
- Cystic fibrosis.
- Roux-en-Y oesophagojejunostomy - eg, for obesity.
- Meckel's diverticulum.
- Peutz-Jeghers syndrome.
- Familial polyposis coli.
- Typically with nonspecific abdominal pain which is recurrent.
- Nausea and vomiting in 20%.
- Change in bowel habit.
- Abdominal distension.
- Palpable mass.
- Decreased or absent bowel sounds.
- Can present with an acute abdomen.
- Bowel obstruction is uncommon.
- Plain abdominal X-rays are not usually helpful but may show a soft tissue mass ± bowel obstruction.
- Barium enema - useful in colonic or ileo-colic intussusception with 'cup-shaped' filling defect.
- Abdominal ultrasonography - may show a 'doughnut' or 'bull's-eye' sign when the intussusception is seen transversely, or 'pseudo-kidney' or 'hayfork' sign in longitudinal section.
- CT scanning is the most effective and accurate diagnostic technique. CT scans may show a 'target lesion' in the distal ileum or ascending colon. It is common to see a target-shaped mass with the oedematous intussuscipiens, surrounding which is the intussusceptum (similar to ultrasonography). CT scanning is probably the imaging modality of choice[8, 10].
- Colonoscopy may visualise the intussusception and can be used to reduce the intussusception - but this depends on the site of the problem and it appears to be better at detecting a neoplastic mass as the lead point; biopsy is not recommended, as there is risk of perforation.
- There is much debate as to the best management of intussusception in adults.
- Many cases of transient intussusception in adults have been observed - especially in conditions that alter GI tract motility.
- Intraoperative reduction before resection has also been attempted but the success rates are rather disappointing and there are concerns that this can lead to intraluminal seeding of malignant cells, perforation and increased risk of complications at the site of anastomoses, due to oedema of the bowel.
- Reduction of the intussuscepted bowel is considered safe for benign lesions in order to limit the extent of resection or to avoid short bowel syndrome.
- One recommendation is that all intussusceptions involving the large bowel should be resected, as there is an almost 60% risk of malignancy, whereas small bowel intussusceptions should be managed by reduction initially, as the risk of a neoplastic lesion is much less.
- GI haemorrhage - either from ileal ulcerations (eg, secondary to heterotopic gastric mucosa) or from mechanical trauma due to repeated intussusception.
- Bowel obstruction ± perforation.
- Sepsis and septicaemia.
- Shock (septicaemic or haemorrhagic).
Further reading and references
Chung CS, Wang MY, Wang HP; A "crescent-in-doughnut" lesion at right lower quadrant abdomen. Gastroenterology. 2009 Jul137(1):e3-4. Epub 2009 May 31.
Correia JD, Lefebvre K, Gray DK; Surgical images: soft tissue. Transverse colonic intussusception. Can J Surg. 2007 Feb50(1):60-1.
Marinis A, Yiallourou A, Samanides L, et al; Intussusception of the bowel in adults: a review. World J Gastroenterol. 2009 Jan 2815(4):407-11.
Roviello F, Caruso S, Moscovita Falzarano S, et al; Small bowel metastases from renal cell carcinoma: a rare cause of intestinal intussusception. J Nephrol. 2006 Mar-Apr19(2):234-8.
Chia AA, Chia JK; Intestinal intussusception in adults due to acute enterovirus infection. J Clin Pathol. 2009 Jul 30.
Koh JS, Hahm JR, Jung JH, et al; Intussusception in a young female with Vibrio gastroenteritis and diabetic ketoacidosis. Intern Med. 200746(4):171-3. Epub 2007 Feb 15.
Ozdogan M, Hamaloglu E, Ozdemir A, et al; Antegrade jejunojejunal intussusception after Roux-en-Y esophagojejunostomy as an unusual cause of postoperative intestinal obstruction: report of a case. Surg Today. 200131(4):355-7.
Zubaidi A, Al-Saif F, Silverman R; Adult intussusception: a retrospective review. Dis Colon Rectum. 2006 Oct49(10):1546-51.
Wang N, Cui XY, Liu Y, et al; Adult intussusception: a retrospective review of 41 cases. World J Gastroenterol. 2009 Jul 1415(26):3303-8.
Harrison LE, Kim SH; Images in clinical medicine. Intussusception of the small bowel. N Engl J Med. 2004 Jul 22351(4):379.
Yalamarthi S, Smith RC; Adult intussusception: case reports and review of literature. Postgrad Med J. 2005 Mar81(953):174-7.
Lu CL, Chen CY, Chiu ST, et al; Adult intussuscepted Meckel's diverticulum presenting mainly lower gastrointestinal bleeding. J Gastroenterol Hepatol. 2001 Apr16(4):478-80.