REVIEW

Adult intussusception: case reports and review of literatureS Yalamarthi, R C Smith. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Postgrad Med J 2005;81:174–177. doi: 10.1136/pgmj.2004.022749

Adult intussusception occurs infrequently and differs fromchildhood intussusception in its presentation, aetiology,and treatment. Diagnosis can be delayed because of itslongstanding, intermittent, and non-specific symptoms andmost cases are diagnosed at emergency laparotomy. Withmore frequent use of computed tomography in theevaluation of patients with abdominal pain, the conditioncan be diagnosed more reliably. Treatment entails simplebowel resection in most cases. Reduction of theintussusception before resection is controversial, but thereis a shift against this, especially in colonic cases. Surgicaltreatment can be difficult in gastroduodenal and coloanalintussusceptions, sometimes requiring innovativetechniques. This paper presents the diagnosis andmanagement of four cases of adult intussusception,followed by review of the literature.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

See end of article forauthors’ affiliations. . . . . . . . . . . . . . . . . . . . . . .

Correspondence to:Mr S Yalamarthi,Department of GeneralSurgery, WarringtonHospital, Lovely Lane,Warrington, OheshireWA5 1QG, UK;satyalam@aol.com

Submitted 11 April 2004Accepted 14 June 2004. . . . . . . . . . . . . . . . . . . . . . .

Intussusception is the telescoping of one seg-ment of the gastrointestinal tract into anadjacent one.1 This condition is uncommon in

adults, with two to three cases occurring in apopulation of 1 000 000 per annum2 andaccounts for less than 0.1% of all adult hospitaladmissions.3 4

The diagnosis in adults is usually made atlaparotomy, as most patients present as anemergency with intestinal obstruction. In non-emergency patients the diagnosis can be chal-lenging as symptoms include intermittentabdominal pain that often settles comparativelyquickly.5 Clinical examination and investigationsare often negative and these patients willprobably be labelled as having irritable bowelsyndrome. Although the surgical treatment isstraightforward in most cases, in some patients,in particular those with gastroduodenal andcoloanal intussusception, the operative aspectcan be challenging.We present four case reports followed by a

literature review.

CASE REPORTSCase 1A 42 year old man was referred by his generalpractitioner with a three day history of melena.He had been investigated previously for irondeficiency anaemia for which no cause wasfound. His haemoglobin was 86 g/l with an irondeficiency picture. An upper gastrointestinal (GI)endoscopy showed minimal oesophagitis. Hesettled with conservative treatment and had anormal barium enema.

When subsequently seen in the clinic, hereported episodic left upper quadrant discomfort.He remained anaemic (haemoglobin 98 g/l)despite taking iron supplements and did nothave any overt blood loss.A barium meal follow through showed dis-

tortion in the terminal ileum; thought tobe extrinsic compression by sigmoid colon.Subsequent computed tomography showed anabnormal area of thickened ileum with a targetappearance (fig 1) and intra-luminal fat, con-sistent with an ileo-ileal intussusception.At laparotomy the radiological findings were

confirmed. A small bowel resection withoutreduction of the intussusception was performed.He made an uneventful postoperative recovery.Pathology showed the lead point to be a Meckel’sdiverticulum (fig 2) with a traumatic ulcer.

Case 2A 71 year old woman was admitted as anemergency with coffee ground vomiting andintermittent, colicky abdominal pain. She hadbeen investigated over the past 18 months forsymptoms of intermittent central and left upperquadrant abdominal pain, vomiting, constipa-tion, weight loss, and anorexia. Upper GIendoscopy on two occasions showed features ofdistal oesophagitis, a sliding hiatus hernia, andduodenitis with positive Helicobacter pylori on oneoccasion. Subsequent barium enema, abdominalultrasound, and small bowel follow throughwere all normal and in view of this she wasthought to have irritable bowel syndrome.During the first 24 hours of admission a

significant decrease in her haemoglobin concen-trations, necessitated blood transfusion. A repeatupper GI endoscopy and a barium follow throughexamination were again unhelpful. She settledwith conservative treatment. An outpatient small

Figure 1 Abdominal computed tomogram showing aclassic target lesion, suggesting ileo-ileal intussusception.

174

www.postgradmedj.com

group.bmj.com on April 9, 2014 - Published by pmj.bmj.comDownloaded from

bowel follow through performed, was also normal. Acomputed tomogram of her abdomen was then obtained,which showed thickening of the jejunal mucosa and a softtissue mass with a doughnut-like appearance in the left iliacfossa. The appearances were suspicious of a small bowelintussusception and a differential diagnosis of a lymphomaor carcinoma was considered.At laparotomy an intussuscepting tumour of the mid-small

bowel was seen. There was extensive fibrosis of the adjacentmesentery, thought to be attributable to the recurrentepisodes of intussusception. A small bowel resection (withoutattempting a reduction) was carried out.Postoperatively she made an uneventful recovery.

Pathology of the resected specimen showed a 30 mm benigntubulovillous adenoma with mild dysplasia.

Case 3A 48 year old man was referred to the surgical outpatientclinic with a three year history of heartburn, bloating, andregurgitation. His medical history included treatment forHelicobacter pylori. Abdominal examination was unremarkableapart from obesity.Initial upper GI endoscopy showed a large sliding hiatus

hernia, but the examination was incomplete because of largefood residue. With a provisional diagnosis of pyloric stenosis,a subsequent barium meal was obtained, which showed alarge filling defect in the second part of the duodenum withvery little contrast passing beyond. Abdominal computedtomography showed a well circumscribed 6 cm duodenalmass, composed almost entirely of fat with some internalseptations. A further upper GI endoscopy confirmed a large

smooth polyp, which was obstructing the lumen of theduodenum. Biopsy specimens showed only normal duodenalmucosa.At laparotomy a large irreducible antral mass that had

intussuscepted into the duodenum was found. The secondpart of the duodenum was opened longitudinally; and themass was shelled out. The duodenotomy was closed in twolayers. Postoperatively the patient made an uneventfulrecovery. The pathology report confirmed the lesion to be asimple lipoma.

Case 4An 84 year old woman residing in a nursing home presentedwith increasing confusion and a prolapsing mass through heranal canal. Over the previous year she had a history ofrecurrent episodes of non-specific abdominal pain anddistension, which were short lasting and did not requirehospital admission.Examination of her abdomen showed slight distension

with minimal tenderness. No masses were palpable. Theperineum showed a prolapsing bowel with an irregular massat the apex. Closer inspection confirmed that this was anintussusception rather than a prolapse and it was presumedto be a prolapse of a tumour of the sigmoid colon.The intussusception was manually reduced. After appro-

priate resuscitation a midline laparotomy was carried out andthe caecum was found to be the intussusceptum. Attempts toreduce this proved impossible, as the caecum could not bereduced out of the rectum. The anterior rectal wall wasopened and the intussuscepting bowel was resected. Havingremoved the mass the two ends of bowel (ileum andtransverse colon) could then be reduced and after trimmingthe bowel ends a functional end to end anastomosis wasfashioned between the ileum and the transverse colon. Theanterior rectal wall was repaired.She made an uneventful recovery. The pathology report

confirmed that the lesion causing the intussusception was alarge villous adenoma of the caecum.

DISCUSSION AND LITERATURE REVIEWThe first report of intussusception was made in 1674 byBarbette of Amsterdam.6 Intussusception or ‘‘introsuscep-tion’’ as it was called then, was in addition detailed in 1789by John Hunter.7 In 1871 Sir Jonathan Hutchinson was thefirst to successfully operate on a child with intussusception.8

Intussusception in adults differs from those in children invarious aspects (table 1).9–13 In adults, 90% occur in the smallor large bowel and, the remaining 10% involve the stomachor a surgically created stoma.14 The single most common siteis the small bowel. Coloanal intussusceptions are rare andusually occur in the setting of a benign or malignanttumour,15 with 50% attributable to a malignant lesion. It isimportant to differentiate this from rectal prolapse, which

Figure 2 Resected specimen showing intussuscepting Meckel’sdiverticulum.

Table 1 Differences between adult and childhood intussusceptions

Children Adult

Percentage of all intussusceptions 95 5Cause of intestinal obstruction Frequent Rare (,5% of all intestinal

obstructions)Aetiology 90%—idiopathic (Peyer’s patch

enlargement in nearly 50%)Rarely idiopathic. Cause identified in70%–90%

Clinical symptoms (classic triad:vomiting, rectal bleeding, andabdominal pain)

Usually present Occurs in only 15%–20%

Treatment Mainly non-operative (bariumhydrostatic reduction)

Surgical resection almost alwaysrequired

Adult intussusception 175

www.postgradmedj.com

group.bmj.com on April 9, 2014 - Published by pmj.bmj.comDownloaded from

can be done by a careful clinical examination. In rectalprolapse continuity can be palpated between the perianal/anal tissue and the protruding tissue, whereas in intussus-ception there is no palpable continuity and the finger can befreely passed between the anorectal wall and the prolapsethroughout the circumference. Gastroduodenal intussuscep-tion, the least frequent of all, is usually caused by theprolapse of a benign gastric tumour into the duodenum, withsubsequent invagination of a portion of the stomach wall.16

The lead points for the intussusceptions are attributable tobenign, malignant, or idiopathic causes.13 14 Although all ourfour patients had a benign pathology, primary or secondarymalignant lesions may account for 6% to 30% of all cases. Inthe review by Felix et al,17 tumour related intussusceptionswere noted in 63% of cases.Intussusception has also been noted in patients with

tropical sprue/coeliac disease,17 abdominal trauma,18 andduring the postoperative period.19 In addition, this conditionhas been noted increasingly among patients with AIDSrelated gut disease, which requires careful consideration.20 21

Idiopathic intussusception in the small bowel accounts for8% to 20% of all cases.9 17

The common intussusceptions have been classified intofour categories according to the site of origin and they are:enteric, ileocolic, ileocaecal, and colonic.22 Enteric and coloniccases are those that are confined to the small and largeintestine respectively. While ileocolic intussusceptions arethose with prolapse of the ileum into the colon through theileocaecal valve, ileocaecal intussusceptions occur when theileocaecal valve acts as the lead point. However, in clinicalpractice it is difficult to differentiate between ileocolic andileocaecal intussusceptions.The presenting symptoms in adult patients with intussus-

ceptions are non-specific and often long standing. Most seriesreport pain as the commonest symptom, being present in 71%to 90% of patients, with vomiting and bleeding from therectum as the next most common symptoms.13 The mostimportant characteristic of pain is its periodic, intermittentnature, which makes the diagnosis elusive and accounts forthe delay in making the diagnosis, with only half the casesbeing diagnosed before operation.13 Abdominal mass is notedin 24% to 42% of cases.9 14

In the review article by Azar et al,9 the mean duration ofsymptoms between onset and presentation was 37.4 days(range 1–365 days). The duration of symptoms was longer inpatients with benign and enteric lesions compared with thosewith malignant and colonic lesions.Computed tomography seems to be the most reliable

investigation in making a preoperative diagnosis, especiallyin those patients with non-specific abdominal pain in whom

the diagnosis can be elusive.1 24 The appearance of intussus-ception is characteristic (table 2), and has been confirmedboth in experimental models and clinical situations.1 25 26

Interestingly, recent experience with computed tomography/magnetic resonance imaging has enabled detection ofvascular compromise27 and it has also been suggested thatlesions detected by these investigations are more likely tohave non-neoplastic causes.28 The accuracy of computedtomography has been confirmed at operation by somestudies.1 29 In our study, computed tomography was carriedout in three patients and it was diagnostic in two patients. Inthe third patient (gastroduodenal intussusception), it showedthe presence of a mass, suggestive of a lipoma.Other investigations like ultrasonography,30 31 barium

enema,9 10 colonoscopy or flexible sigmoidoscopy,32 upper GIseries,33 can be used according to the clinical situation.Adult intussusception warrants laparotomy rather than

attempts at hydrostatic reduction in view of the highincidence of underlying abnormlity.9 23 Controversy remainsas to whether reduction of the intussuscepting lesion shouldbe attempted at operation. Early reports advocated reducingthe intussusception before resection.3 4 The perceived dis-advantage of this is that malignant cells may be disseminatedduring the process despite no clear evidence on this issue. Onthe other hand, the advantages of reducing the intussuscep-tion especially when the small bowel is affected are that itmay be possible to preserve considerable lengths of boweland thereby prevent development of short bowel syndrome.Begos et al23 suggest resection without attempting reduc-

tion when the bowel is inflamed, ischaemic, or friable and inobvious colo-colic intussusception (given the high likelihoodof malignancy). In all other cases reduction should always beattempted initially. However, Azar et al8 suggested thatsurgical resection without reduction is the preferred treat-ment in adults, as almost 50% of both colonic and entericintussusceptions are associated with malignancy. Simplereduction is however acceptable in post-traumatic andidiopathic intussusceptions where no pathological cause isusually present in the bowel.32

Treatment of gastroduodenal intussusceptions usuallyentails reduction of the intussusception and surgical excisionof the lead point, either endoscopically or through a formallaparotomy.16 In coloanal intussusceptions, the preferredapproach is to reduce the intussusception before resection.This could lead to a sphincter saving operation as comparedwith an abdominoperineal resection.16 However, it is notalways easy to reduce the intussusception and there is a riskof disseminating cancer cells. Abdominal resection is thepreferred method but perineal approaches have also beentried. Our experience with the coloanal and gastroduodenal

Table 2 Main computed tomographic findings inpatients with adult intussusception

Finding Explanation

Apparent mass lesion* Caused by thickened segment of bowel(the intussusceptum telescoping into theintussuscipiens)

A crescent-like, eccentric lowattenuation fatty mass*

Represents the entrapped mesenteric fat.

A rim of contrast materialencircling the intussusceptum�

Represents coating of the opposingbowel walls of the intussusceptum andthe intussuscipiens.

Air bubbles Occurs peripheral to the upper part ofthe intussusception and may lie betweenthe opposing bowel walls.

*Combination of these two lesions produces a target or sausage shapedmass. �This feature is analogous to the coil spring appearance seen on abarium enema.

Key points

N Intussusception in adults is an infrequent cause ofintestinal obstruction.

N Preoperative diagnosis is difficult as symptoms can beintermittent and long standing.

N More frequent use of computed tomography inundiagnosed abdominal pain increases the pick uprates.

N Surgical treatment is required in all patients and thereis more emphasis towards resection without reductionin most cases.

N Innovative surgical techniques may be required ingastroduodenal and coloanal intussusceptions.

176 Yalamarthi, Smith

www.postgradmedj.com

group.bmj.com on April 9, 2014 - Published by pmj.bmj.comDownloaded from

cases shows that the operative procedure may need innova-tive techniques and can be challenging, especially with theformer.

CONCLUSIONSIntussusception in adults is an infrequent problem. Thediagnosis of this condition can be difficult as symptoms areoften non-specific and episodic. It is important to have a highindex of suspicion. The most useful investigation is abdom-inal computed tomography. Treatment requires resection ofthe involved bowel without attempted reduction in coloniclesions and in small bowel cases where the bowel is non-viable or where malignancy is suspected. With gastroduode-nal and coloanal intussusceptions the surgical technique mayneed modification according to the situation and can bechallenging.

Authors’ affiliations. . . . . . . . . . . . . . . . . . . . .

S Yalamarthi, R C Smith, Department of General Surgery, Falkirk Districtand Royal Infirmary, Falkirk, Scotland

Funding: none.

Conflicts of interest: none declared.

REFERENCES1 Gayer G, Apter S, Hofmann C, et al. Intussusception in adults: CT diagnosis.

Clin Radiol 1998;53:53–7.2 Carter CR, Morton AL. Adult intussusception in Glasgow, UK. Br J Surg

1989;76:727.3 Donhauser DL, Kelly EC. Intussusception in the adult. Am J Surg

1950;79:673–7.4 Brayton D, Norris WJ. Intussusception in adults. Am J Surg 1954;88:32–43.5 Gordon RS, O’Dell KB, Namon AJ, et al. Intussusception in adults—a rare

disease. J Emerg Med 1991;9:337–42.6 Barbette P. Ouevres Chirurgiques at Anatomiques. Geneva: Francois Miege,

1674.7 Hunter J. On introsusception (read Aug 18, 1789). In: Palmer JF, ed. The

works of John Hunter, FRS London. London: Longman, Rees, Orme, Brown,Green, Longman, 1837:587–93.

8 Hutchinson J. A successful case of abdominal section for intussusception.Proc R Med Chir Soc 1873;7:195–8.

9 Azar T, Berger DL. Adult intussusception. Ann Surg 1997;226:134–8.10 Nagomey DM, Sarr MG, McIlrath DC. Surgical management of

intussusception in the adult. Ann Surg 1981;193:230–6.

11 Agha FP. Intussusception in adults. Am J Roentgenol 1986;146:527–31.12 Adebamowo CA, Akang EE, Pindiga HU, et al. Changing clinicopathological

profile of intussusception in Nigeria—a 20-year review.Hepatogastroenterology 2000;47:437–40.

13 Reijnen HA, Joosten HJ, De Boer HH. Diagnosis and treatment of adultintussusception. Am J Surg 1989;158:25–8.

14 Stubenord WT, Thorblamarson B. Intussusception in adults. Ann Surg1970;172:306–10.

15 Nesbakken A, Haffner J. Colo-recto-anal intussusception: case report. ActaChir Scand 1989;155:201–4.

16 Lin F, Setya V, Signor W. Gastroduodenal intussusception secondary to agastric lipoma: a case report and review of literature. Am Surg1992;58:772–4.

17 Felix EL, Cohen MH, Bernstein AD, et al. Adult intussusception: case report ofrecurrent intussusception and review of the literature. Am J Surg1976;131:758–61.

18 Brooks A, Bebington BD, Lucas S, et al. Intussusception caused by bluntabdominal trauma. J Trauma 1999;47:156–7.

19 Eke N, Adotey JM. Post operative intussusception, causal or casualrelationship? Int Surg 2000;85:303–8.

20 Dannin JC, McCarty M, Coker R. Case Report: Lymphoma causing smallbowel intussusception in a patient with the acquired immune deficiencysyndrome. Clin Radiol 1992;46:350–1.

21 Meyerson S, Desai TK, Polidori G, et al. A case of intussusception andlymphoid hyperplasia in a patient with AIDS. Am J Gastroenterol1993;88:303–6.

22 Weilbaecher D, Bolin JA, Hearn D, et al. Intussusception in adults: Review of160 cases. Am J Surg 1971;121:531–5.

23 Begos DG, Sandor A, Modlin IM. The diagnosis and management of adultintussusception. Am J Surg 1997;73:88–94.

24 Takeuchi K, Tsuzuki Y, Ando T, et al. The diagnosis and treatment of adultintussusception. J Clin Gastroenterol 2003;36:18–21.

25 Bar-ZivJ, Solomon A. Computed tomography in adult intussusception.Gastrointest Radiol 1991;16:264–6.

26 Gayer G, Zissin R, Apter S, et al. Pictorial review: adult intussusception—a CTdiagnosis. Br J Radiol 2002;75:185–90.

27 Fujimoto T, Fukuda T, Uetani M, et al. Unenhanced CT findings of vascularcompromise in association with intussusceptions in adults. Am J Roentgenol2001;176:1167–71.

28 Warshauer DM, Lee JK. Adult intussusception detected at CT or MR imaging:clinical—imaging correlation. Radiology 1999;212:853–60.

29 Barbiera F, Cusma S, Di Giacomo D, et al. Adult intestinal intussusception:surgery-CT correlation. Radiol Med 2001;102:37–42.

30 Boyle MJ, Arkell LJ, Williams JT. Ultrasonic diagnosis of adult intussusception.Am J Gastroenterol 1993;88:617–18.

31 Lim JH, Ko JT, Lee DH, et al. Determining the site and causes of colonicobstruction with sonography. Am J Roentgenol 1994;163:1113–17.

32 Kitamura K, Kitagawa S, Mori M, et al. Endoscopic correction ofintussusception and removal of a colonic lipoma. Gastrointest Endosc1990;36:509–11.

33 Wiot JF, Spitz HB. Small bowel intussusception demonstrated by oral barium.Radiology 1970;97:361–6.

Adult intussusception 177

www.postgradmedj.com

group.bmj.com on April 9, 2014 - Published by pmj.bmj.comDownloaded from

doi: 10.1136/pgmj.2004.022749 2005 81: 174-177Postgrad Med J

 S Yalamarthi and R C Smith review of literatureAdult intussusception: case reports and

http://pmj.bmj.com/content/81/953/174.full.htmlUpdated information and services can be found at:

These include:

References

http://pmj.bmj.com/content/81/953/174.full.html#related-urlsArticle cited in:  

http://pmj.bmj.com/content/81/953/174.full.html#ref-list-1This article cites 30 articles, 1 of which can be accessed free at:

serviceEmail alerting

box at the top right corner of the online article.Receive free email alerts when new articles cite this article. Sign up in the

Notes

http://group.bmj.com/group/rights-licensing/permissionsTo request permissions go to:

http://journals.bmj.com/cgi/reprintformTo order reprints go to:

http://group.bmj.com/subscribe/To subscribe to BMJ go to:

group.bmj.com on April 9, 2014 - Published by pmj.bmj.comDownloaded from