most common site of intussusception in adults

This controversy is related to the consideration that reducing the intussusception before resection carries risks of perforation and the theoretical possibility of dissemination of malignant cells during the attempt. The upper gastrointestinal structures, specifically the esophagus, stomach, and duodenum, are rarely involved in intussusception due to their lack of mobility, redundancy, and characteristic anatomic fixation. On the other hand, intussusception with an organic lesion as the lead point usually presents with the clinical picture of bowel obstruction (15, 16). Accessibility sharing sensitive information, make sure youre on a federal Adult intussusception; case report of recurrent intussusceptions and review of the literature. Lianos G, Xeropotamos N, Bali C, Baltoggiannis G, Ignatiadou E. Adult bowel intussusception: presentation, location, etiology, diagnosis and treatment. Classic findings on CT include target, bulls-eye, or sausage-shaped lesions as a concentric hyperdense double ring, features owing to the anatomic configuration of the outer intussuscipiens and the central intussusceptum creating a bowel-within-bowel appearance (Figs. 10 Independent predictors of malignancy include colonic intussusception and anemia (hemoglobin <12 g/dL). Similar to infectious causes, hypertrophy of Peyer patches and/or mesenteric lymphadenopathy can act as a lead point. West K W, Stephens B, Vane D W, Grosfeld J L. Intussusception: current management in infants and children. Online content including video sequences viewable at: www.thieme-connect.com/ejournals/html/doi/10-1055-s-0036-1593429-ccrs-765-v1.mp4. In: StatPearls [Internet]. Malrotation is another etiology of intussusception in a condition called Waugh syndrome.5 Interestingly, some authors suggest intestinal resection without reduction when the bowel is inflamed and ischaemic. Erkan N, Haciyanli M, Yildirim M, Sayhan H, Vardar E, Polat AF. Lvoff N, Breiman R S, Coakley F V, Lu Y, Warren R S. Distinguishing features of self-limiting adult small-bowel intussusception identified at CT. Jain P, Heap S W. Intussusception of the small bowel discovered incidentally by computed tomography. We herein discuss the epidemiology and the clinical features of bowel intussusception in adult and the role of radiology and surgery in the management of this insidious condition. 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. Unlike plain films, the sensitivity and specificity of ultrasound in diagnosing intussusception approaches nearly 100% in experienced hands, especially in children.24 Due to the noninvasive nature of ultrasound, it is the imaging modality of choice for evaluating children, and has been found to be a rapid, sensitive screening procedure in the assessment for intussusception. Al-Momani H. Waugh syndrome: a report of 7 patients and review of the published reports. Approach to management of intussusception in adults: a new paradigm in the computed tomography era. The reported drawbacks of this method is that malignant cells may be disseminated during the attempt. However, the extent of bowel resection and the manipulation of the intussuscepted bowel during reduction remain to be clarified. Historically, adult intussusceptions have been treated surgically due to the association of pathology serving as lead point. Eisen LK, Cunningham JD, Aufses AH Jr. Intussusception in adults: institutional review. At the time of surgery for malrotation and intussusception, the diagnosis is usually made and confirmed by the location of the cecum and the pathognomic presence of peritoneal bands from the ascending colon across the duodenum. Intussusception refers to the invagination (telescoping) of a part of the intestine into itself. McKay R. Ileocecal intussusception in an adult: the laparoscopic approach. and transmitted securely. Mrak K. Uncommon conditions in surgical oncology: acute abdomen caused by ileocolic intussusception. In children, it is usually primary and benign, and pneumatic or hydrostatic reduction is the sufficient treatment in 80% of patients (9). Presentation often includes colicky abdominal pain, flexing of the legs, fever, lethargy, and vomiting, with blood in the stool in some cases. 8600 Rockville Pike As a library, NLM provides access to scientific literature. There are four types: ileocolic, ileo-ileocolic, colo . Gupta RK, Agrawal CS, Yadav R, Bajracharya A, Sah PL. It is the most common abdominal emergency in early childhood, particularly in children younger than two years of age [ 1 ]. 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. Based on the systematic review of Hong et al[12] the pooled rates of enteric, ileocolic, and colonic location types account for 49.5%, 29.1%, and 19.9%, respectively. FOIA 1Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, 2Geisel School of Medicine, Hanover, New Hampshire, 3The Dartmouth Institute for Health Policy & Clinical Practice, Lebanon, New Hampshire. 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 diagnosis is typically made intraoperatively or by cross-sectional imaging. National Library of Medicine Intussusception is defined as invagination of one segment of the bowel into an immediately adjacent segment. Intussusception, more common occur in the small bowel and rarely involve only the large bowel. To make a correct differential diagnosis with other similar intestinal pathologies, it is therefore useful to use radiodiagnostic instruments: abdomen X-ray, small bowel series with barium, abdominal ultrasound, abdominal CT. Intussusceptions are classified according to location (enteroenteric, ileocolic, ileocecal, or colo-colic) and cause (benign, malignant, or idio-pathic). 19,20 In this study, the ileocolic type was the most common, occurring in 10 (36%) patients, and the . 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. Clinicians and surgeons are not supported by designated scoring systems in this challenging diagnosis because of non-specific symptoms, and its preoperative identification is often missed or delayed. Cakir M, Tekin A, Kucukkartallar T, Belviranli M, Gundes E, Paksoy Y. Intussusception: as the cause of mechanical bowel obstruction in adults. Rea JD, Lockhart ME, Yarbrough DE, Leeth RR, Bledsoe SE, Clements RH. Yakan S, Caliskan C, Makay O, Denecli A G, Korkut M A. Intussusception in adults: clinical characteristics, diagnosis and operative strategies. Symptoms can be acute, intermittent or chronic (14). Intussusception (in-tuh-suh-SEP-shun) is a serious condition in which part of the intestine slides into an adjacent part of the intestine. Laboratory tests usually document increase of leukocytes count and inflammatory markers such as polymerase chain reaction. The choice of preforming laparoscopic rather than open procedure depends both on the clinical condition of the patient and on surgeons laparoscopic experience[8,27]. Beatrice Di Venere, Department of Surgery, "Madonna delle Grazie" Hospital, Matera 75100, Italy. Eisen L K, Cunningham J D, Aufses A H Jr. Intussusception in adults: institutional review. Andrea Mardighian, Interventional Radiology Unit, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Bari, Italy. 8 Regarding surgical approach, for open cases (i.e., laparotomy) standard surgical technique using a midline incision and wound protector with or without a fixed retracting system (i.e., Bookwalter) is used. Thiago Franchi Nunes, Department of Radiology, Santa Casa de Campo Grande, Campo Grande 79010-050, Brazil. Adult intestinal intussusception: CT appearances and identification of a causative lead point. Long-segment Ileoileal adult intussusception with classic bulls-eye appearance with concentric rings (left panel) and trilaminar appearance (right panel). This process can lead to multiple complications such as bowel obstruction, bowel necrosis, and sepsis. (Images courtesy of Dr. Nancy McNulty, MD.). Although intussusception can occur anywhere in the gastrointestinal tract, it usually occurs at the junction of the small and large intestines. 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. Infectious etiology resulting in mesenteric lymphadenopathy is another common cause of pediatric intussusception. Current surgical therapy. Gayer G, Zissin R, Apter S, et al. In the case of pediatric intussusception, only 5-mm ports are used and the reduction can be performed entirely intracorporeally (Video 1). Intussusception is far more common in children, which account for 95% of all cases As nonoperative reduction is a common practice for pediatric intussusception, practitioners should be aware of the possibility of Waugh syndrome. Buettcher et al found a seasonal variation of intussusception that correlated with seasonal variation of viral gastroenteritis.4 Approximately 30% of patients experience an antecedent viral illness before the onset of intussusception. As opposed to the pediatric population, adult intussusception is commonly caused by a pathologic lead point; it can be located in the lumen of the bowel, inside the wall or extramural[8], and its occurrence is associated to an identifiable cause in 80%-90% of symptomatic cases[7,9,10]. 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). Although the exact mechanism leading to intussusception is unknown, it is believed that any lesion in the bowel wall or irritant within the lumen that alters normal peristaltic bowel activity is able to initiate the invagination process. Dexamethasone may decrease the risk of another episode. Wang L T, Wu C C, Yu J C, Hsiao C W, Hsu C C, Jao S W. Clinical entity and treatment strategies for adult intussusceptions: 20 years experience. When lead point pathology is present in adult small bowel intussusception, it is usually benign, though when malignant it is most frequently due to diffuse metastatic disease, for example, melanoma. 8 In these setting, preoperative endoscopy can be done in order to confirm the presence of pathology and/or cancer[8]. Interestingly, an abdominal mass associated with colicky pain, nausea, vomiting, change in bowel habits, constipation, hypoactive to absent bowel sounds, and bleeding are often present. Elm'hadi C, Tarchouli M, Khmamouche M R. et al. Intussusception is a condition in which part of the intestine folds into the section next to it. government site. Bethesda, MD 20894, Web Policies 17 Wang et al found abdominal cramping pain in nearly 80% of patients as a leading symptom; a palpable abdominal mass, however, was found in less than 9%.10 Symptoms are typically acute, lasting days to weeks,15 but rarely can be chronic, lasting years.18 The onset and duration of clinical symptoms is significantly longer in large bowel than in small bowel disease, 62.5 versus 35.7% respectively.19. Diagnosis and treatment of adult intussusception. [1][2][3][4] Inclusion in an NLM database does not imply endorsement of, or agreement with, Intussusception can also be caused by noninfectious etiologies, such as intestinal allergies, Celiac disease, and Crohn disease. MRI is not routinely used in the pediatric or adult populations in the diagnosis of intussusception, but its sensitivity may be similar to CT, especially when an enterography protocol is used (Fig. We have to highlight the high index of suspicion that is necessary for the operating surgeon, when dealing with acute, subacute or chronic abdominal pain in adults, because any misinterpretation may result in unfavorable outcomes. A causal lesion is identified in 90% of these cases (5, 6). In either case, quick, less invasive, and less costly approaches are initially employed in the making of the diagnosis. and transmitted securely. The management of bowel intussusception in adult remains mainly surgical. Interestingly, intussusceptions have been classified according to their locations into four categories: (1) entero-enteric (confined to the small bowel), (2) colo-colic (involving the large bowel), (3) ileo-colic (prolapse of the terminal ileum within the ascending colon) and (4) ileo-cecal, (the ileo-cecal valve is the leading point of the intussusception) (18, 19). Cerro P, Magrini L, Porcari P, De Angelis O. Sonographic diagnosis of intussusceptions in adults. 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]. Abbreviations: Abd, abdominal; constip, constipation; Dx, diagnosis; GI, gastrointestinal; ICV, ileocolic volvulus; LB, large bowel; malig, malignant; N/V, nausea/vomiting; SB, small bowel; sx, symptoms. Ileocolic intussusception is the most common form of intussusception in children. Adult intussusception: case reports and review of literature. Additionally, decreased reliability was noted due to air levels in the bowel, a large amount of feces in the colon and malrotation. With continued invagination resulting in edema, eventually the vascular flow to the bowel becomes compromised, resulting in ischemia to the affected segment that, left untreated, can result in necrosis and perforation. Generally, resection of the pathologic and/or ischemic segment of bowel with creation of a primary surgical anastomosis can be performed in entero-enteric intussusceptions and right-sided colocolonic or ileocolic intussusception. With increasing age, the likelihood of identifiable causes of intussusception increases. Boudiaf M, Soyer P, Terem C, Pelage JP, Maissiat E, Rymer R. Ct evaluation of small bowel obstruction. Chiang J M, Lin Y S. Tumor spectrum of adult intussusception. The nomenclature of intussusception reflects location of both the intussusceptum and intussuscipiens in the bowel: enteroenteric, appendiceal, appendiceal-ileocolic, ileocolic, colocolic, rectoanal, and stomal intussusception. Kim Y H, Blake M A, Harisinghani M G. et al. Video 1 Takeuchi K, Tsuzuki Y, Ando T, Sekihara M, Hara T, Kori T, Kuwano H. The diagnosis and treatment of adult intussusception. official website and that any information you provide is encrypted The most common Careers, Unable to load your collection due to an error. Bar-Ziv J, Solomon A. Computed tomography in adult intussusception. Typical are also considered mesenteric vessels within the intestinal lumen (30). Blood loss or a palpable mass are present in a minority of cases. National Library of Medicine This clinical entity was first described in 1674 by Barbette of Amsterdam and presented in 1789 by John Hunter as introssusception, a rare form of bowel obstruction in the adult (2). 5). It is reported in literature that the first to operate on a child with intussusception was Sir Jonathan Hutchinson in 1871 (3, 4). 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). Begos D G, Sandor A, Modlin I M. The diagnosis and management of adult intussusception. In contrast, adult ileocolic and colonic intussusception lead point pathology is most frequently primary adenocarcinoma when malignant. Gennaro Nasti, Department of Surgery, "Madonna delle Grazie" Hospital, Matera 75100, Italy. It is recommended to sample suspected fluid collections for culture as well as to biopsy suspected lesions. Another transient phenomenon is the inverted appendix, which, after ruling out mass lesion by cross-sectional imaging, can often be observed. Is also reported recently that abdominal CT is able to distinguish between intussusception without a lead point including images of no proximal bowel obstruction, target-like or sausageshaped mass and layering effect from intussusception with a lead point providing characteristic images such as signs of bowel obstruction, bowel wall edema with loss of the classic three-layer appearance due to impaired mesenteric circulation (31). Ghaderi H, Jafarian A, Aminian A, Mirjafari Daryasari SA. As a library, NLM provides access to scientific literature. In coloanal intussusceptions, the preferred approach is to reduce the intussusception and then proceed with the resection (37). In the pediatric population, ileocolic intussusception is the most common type. Treatment of gastroduodenal intussusceptions usually entails reduction of the intussusception and surgical excision of the lead point. Federal government websites often end in .gov or .mil. On the other hand, the reduction of bowel intussusception is useful both to preserve important lengths of small bowel and to prevent possible development of short bowel syndrome, especially when the small bowel is the only tract involved because of its lower rate of association to malignancy[29,30]. [1] Signs and symptoms Azar T, Berger D L. Adult intussusception. In contrast to children, where intussusception is benign, preoperative reduction with barium or air is not recommended for adults. 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. It is rarer in adults and is. (Images courtesy of Dr. Nancy McNulty, MD.). Plain films will typically reveal signs of intestinal obstruction or perforation, which may include massively distended loops of bowel with absence of colonic gas, as well as information on the location of the obstruction in the gastrointestinal tract.14 Additional radiographic findings include a target sign, consisting of two concentric radiolucent circles superimposed on the right kidney which represents peritoneal fat surrounding the intussusception21; an obscured liver margin22; or lack of air in the cecum, preventing its visualization.

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