Adult Intussusception

First detailed report of the condition was provided by John Hunter (1789), the term ‘intussusception’ defines telescoping of proximal bowel segment (Intussusceptum) into the lumen of adjacent distal segment (Intussuscipiens).

Adult intussusception is a rare condition and represents 1% of bowel obstruction. A study by Massachusetts General Hospital reported only 58 adult patients over 30 years (1964 – 1993).¹ Similarly a subsequent French multicentre study also reported 44 cases over 25 years (1979 – 2004).²

Over the last 7 years, we have managed 7 patients of this rare entity. Our experience is presented through representative cases.

Patient 1

A 53 year male patient presented with 6 months history of recurrent pain abdomen with vomiting with weight loss. His abdominal CT scan showed proximal small bowel tumor with intussusception (Figure 1 & 2). At laparotomy there was a 5 x 3 cm tumor in the jejunum just distal to duodenojejunal flexure with jejuno –jejunal intussusception. The patient underwent pancreas preserving distal duodenectomy (PPDD) with side to side duodenojejunal anastomosis. Biopsy was suggestive of spindle cell tumor (T2bN0, 11 lymph nodes; all negative, Ki 67 Index 40-50%). At immunohistochemistry the tumor cells were strongly positive for SMA, Vimentin, caldesmon and negative for CD 117, CD 34, S-100 & CK. Hence a diagnosis of primary leiomyosarcoma of small bowel was made.

Figure1 & 2.Proximal small bowel tumor with intussusception   

     

Patient 2

A healthy woman in her 4^th decade presented to triage with pain abdomen & vomiting for 7 days. Abdominal CT scan was suggestive of Ileo-ileal intussusception. At laparotomy there was Ileo-ileal intussusception with pedunculated tumor in ileum acting as lead point (Figure 3, 4). A laparoscopy assisted segmental bowel resection was performed.

Figure 3. Ileo-ileal intussusception

Figure 4. Lead point - pedunculated ileal tumor

Patient 3

A 20 year male patient on investigation for recurrent abdominal pain was found to have large seesile lipoma in the ascending colon with colo-colic intussusception on abdominal CT scan (Figure5,6). He underwent laparoscopic assisted segmental colectomy.

                    

Figure 5. Lipoma ascending colon

Figure 6. Colo-colic intussusception - Lipoma as lead point

Patient 4        

A 40 year male patient underwent Roux en Y cystojejunostomy for symptomatic giant pseudocyst of pancreas that had developed following acute biliary pancreatitis. He reported 6 months later with clinical features suggestive of acute intestinal obstruction. His abdominal CT scan was suggestive small bowel intussusception. There were radiological features suggestive of advanced disease in the form of amorphous nature of the Intussusceptum with intramural air (Figure 7). At laparotomy the pseudocyst from previous surgery was no longer visible. The Roux limb of cystojejunostomy has intussuscepted completely resulting in an affected small bowel segment of approximately 150 cm. In view of the large segment involved an attempt was made at manual reduction so as to conserve as much small bowel as possible. However this resulted in rupture of intussuscipiens which revealed Intussusceptum with gangrenous tip. Resection of this large affected segment with primary anastomosis was then performed. The patient had an uncomplicated recovery. 

         

Figure 7. Intussusception with intramural air 

 Figure 8.Intussusceptum with gangrenous tip

Discussion

In adults, the lead point for intussusception is usually an intraluminal organic lesion e.g. tumor in the affected bowel segment. In postoperative intussusception, suture line of previous enterotomy or adhesions may serve as lead point. Abdominal contrast enhanced CT scan is the most useful diagnostic modality that can provide a preoperative diagnosis of intussusception. The intussusceptum in the centre and the edematous intussuscipiens forms the external ring thereby giving the appearance of ‘target sign’.^1,3 In advanced cases with intestinal necrosis, appearance is that of amorphous mass with mural air.

In adult intussusception, the treatment of choice is segmental resection without reduction. In rare instances where bowel resection is likely to result in loss of substantial length of bowel, reduction may be attempted. However in advanced cases this may result in bowel rupture involving Intussuscpiens.

 References 

1.      Azar T, Berger D. Adult Intussusception Ann Surg 1997;226: 134-138  

2.      Barussaud M, Regenet N, Briennon X.  Clinical spectrum and surgical approach of adult intussusceptions: a multicentric study. Int J Colorectal Dis 2006;21(8):834-9

3.      Vashistha N, Singhal D. Elderly woman with acute abdomen and gastric mass on imaging. JAMA Surg 2016 May 1;151(5):481-2 (https://jamanetwork.com/journals/jamasurgery/article-abstract/2499490)

Authors:

Dr Nitin Vashistha, MS, FIAGES, FACS

Dr Dinesh Singhal, MS, FACS, DNB (Surg Gastro)

Department of Surgical Gastroenterology,
Max Super Speciality Hospital, Saket, New Delhi, India
E mail: gi.cancer.india@gmail.com

www.gicancerindia.com

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