most common site of intussusception in adults

Literature report that about 90% of intussusceptions in adults have a lead point. Preoperative diagnosis is often missed or delayed because of non-specific symptoms. Intussusception is defined as the 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. Intussusception is most commonly encountered in children and has been reported to be the most common abdominal emergency in early childhood and the second most common cause of intestinal obstruction after pyloric stenosis.1 The mean age of intussusception in children is 6 to 18 months, with a male predominance. government site. The result is bowel obstruction and inflammatory bowel changes ranging from thickening to ischemia of the intestine wall (21). Intussusception most commonly occurs in infants aged between 3 and 12 months, with a peak at the age of approximately 9 months. It is especially useful in colic or ileocolic intussusception.18 In the pediatric population, hydrostatic or pneumatic enema is limited to therapeutic applications. Martn-Lorenzo J G, Torralba-Martinez A, Lirn-Ruiz R. et al. Conflict-of-interest statement: All the authors are aware of the content of the manuscript and have no conflict of interest. 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. In the pediatric population, treatment depends on the type of intussusception. 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. Part of a proximal segment of the bowel slides into the next distal section. In addition, most surgeons agree that adult intussusception requires surgical resection because the majority of patients have intraluminal lesions. This predominance of enteric intussusception has its exception in the populations of the central and western Africa in which is most common the cecocolic intussusception (tropical intussusception)[14] probably for the interaction of dietary habits (high-fiber diet), genetics and gut microbiome features. Dexamethasone may decrease the risk of another episode. The site is secure. Weihmiller S N, Buonomo C, Bachur R. Risk stratification of children being evaluated for intussusception. Undoubtedly, other controversy remains as to whether reduction of the intussusception should be attempted intraoperatively[27,28]. Treatment of gastroduodenal intussusceptions usually entails reduction of the intussusception and surgical excision of the lead point. Inflammatory fibroid polyp (IFP) is one of the rarest benign tumors of the gastrointestinal tract. Intussusception: Causes, symptoms, and treatment - Medical News Today 10 The most common lesions are Meckel diverticulum and adhesions.8 Benign tumors include lymphoid hyperplasia, lipomas, leiomyomas, hemangiomas, and polyps. Predictive factors of malignancy in adults with intussusception. 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. Usually the most common site is the small bowel. Zubaidi A, Al-Saif F, Silverman R. Adult intussusception: a retrospective review. Mrak K. Uncommon conditions in surgical oncology: acute abdomen caused by ileocolic intussusception. 32 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). Any perturbation of the normal pattern of intestinal peristalsis increase the risk of intussusception[7]. Children younger than 2 years classically present with acute onset colicky abdominal pain, knees drawn to chest, with excessive irritability and crying. This event can lead to bowel obstruction and intestinal ischemia. 4 Several types of intussusception occur in adults. On the other hand, intussusception with an organic lesion as the lead point usually presents with the clinical picture of bowel obstruction (15, 16). FOIA 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. 9. 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. Abdominal mass is noted in 24% to 42% of cases. As a library, NLM provides access to scientific literature. Inflammatory fibroid polyp of the small intestine. The diagnosis and management of adult intussusception. (23M, mp4) Intracorporeal reduction of pediatric intussusception using 5-mm ports. It is reported that common physical findings include abdominal distension and tenderness. Intussusception: Symptoms, Causes, Diagnosis & Treatment - Healthline Functional bowel disorders, and poorly understood neuroenteric disorders such as small intestinal pseudoobstruction, can alter peristalsis and result in intussusception in a similar fashion. An official website of the United States government. This event can lead to bowel obstruction and intestinal ischemia. Evaluation often starts with plain films of the abdomen (acute abdominal series). Received 2021 Jan 18; Revised 2021 Feb 15; Accepted 2021 Mar 18. 44).13 33 As opposed to the pediatric population, the treatment of intussusception causing obstruction in adults typically involves surgery, often with bowel resection. Wang LT, Wu CC, Yu JC, Hsiao CW, Hsu CC, Jao SW. Clinical entity and treatment strategies for adult intussusceptions: 20 years' experience. Distinguishing features of self-limiting adult small-bowel intussusception identified at CT. Jain P, Heap SW. Intussusception of the small bowel discovered incidentally by computed tomography. Most Adult Intussusceptions are Caused by Tumors: A Single-Centre Decreased or absent bowel sounds, guaiac-positive stool, and an abdominal mass may be present.16 If the presentation is late in the course of the disease, the patient may present with signs of peritonitis or bowel ischemia with pain out of proportion to physical exam findings. 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. Intussusception refers to the invagination (telescoping) of a part of the intestine into itself. The risk of preliminary manipulation includes tumor dissemination. Undoubtedly, controversy remains as to whether reduction of the intussusception should be attempted intraoperatively. Video 1 Additionally, decreased reliability was noted due to air levels in the bowel, a large amount of feces in the colon and malrotation. Symptoms occur due to continued peristaltic contractions of the intussuscepted segment against the obstruction. Eisen LK, Cunningham JD, Aufses AH Jr. Intussusception in adults: institutional review. This was owing to potentially limiting factors such as bowel wall edema and sigmoid volvulus, which appear on ultrasound with the same target and ox eye signs as intussusception. Although intussusception can occur anywhere in the gastrointestinal tract, it usually occurs at the junction of the small and large intestines. official website and that any information you provide is encrypted When a preoperative diagnosis of a benign lesion is established, the operating surgeon may reduce the intussusception and proceed, if necessary, to limited resection. Interestingly, transient non-obstructing intussusception without a lead point has been described in patients with celiac or Crohns disease, but is more frequently idiopathic and resolves spontaneously without any type of intervention. Adult intussusception: experience in Singapore. Small bowel intussuscept ion demonstrated by oral barium. 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. The https:// ensures that you are connecting to the It is recommended to sample suspected fluid collections for culture as well as to biopsy suspected lesions. Saverino B P, Lava C, Lowe L H, Rivard D C. Radiographic findings in the diagnosis of pediatric ileocolic intussusception: comparison to a control population. 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. Inclusion in an NLM database does not imply endorsement of, or agreement with, 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. Symptoms in these cases are aspecific and include intermittent abdominal pain (8). Adult intussusception: a systematic review and meta-analysis. In central and western Africa, primary adult intussusception is known as Ibadan intussusception or tropical intussusception and is most commonly cecocolic.11 This geographic variation in pathology has been attributed to the fiber content of the diet, dietary habits, genetics, and gut microbiome composition. Barbiera F, Cusma S, Di Giacomo D, et al. Summary. Treasure Island (FL): StatPearls Publishing; 2021. ti.liamtoh@niodraccir. On the other hand, almost 90% of adults intussusceptions are secondary to a pathologic condition that serves as a lead point. The clinical presentation of intussusception is variable but generally marked by abdominal pain and signs of bowel obstruction. Reijnen HA, Joosten HJ, de Boer HH. Hunter J. 2020 Dec 7. The etiology of intussusception in children is typically idiopathic, often influenced by anatomic or infectious factors (Table 1). This movement causes the intestine to fold around itself, the way the parts of a telescope fit around. 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]. The reported drawbacks of this method is that malignant cells may be disseminated during the attempt. However, the extent of resection and whether the intussusception in adults should be reduced remains controversial (12). If needed, other ports can be placed depending on the location of the pathology. Hypertrophy of the Peyer patches in the setting of common viral illness such as adenovirus and rotavirus can lead to intussusception. 10 The most common symptoms correspond to the symptoms of intestinal obstruction, including abdominal pain, nausea, vomiting, bloating and tenderness. Intussusception - an overview | ScienceDirect Topics The ileocolic region is the most common site of intussusception. Intussusception is a common and often benign condition in the pediatric population, and can usually be managed nonoperatively. Hanan B, Diniz TR, da Luz MM, da Conceio SA, da Silva RG, Lacerda-Filho A. Intussusception in adults: a retrospective study. What Is Intussusception? - WebMD Riccardo Inchingolo, Interventional Radiology Unit, "F. Miulli" General Regional Hospital, Acquaviva delle Fonti 70021, Bari, Italy. Laboratory tests usually document increase of leukocytes count and inflammatory markers such as polymerase chain reaction. The https:// ensures that you are connecting to the The .gov means its official. Wang LT, Wu CC, Yu JC, Hsiao CW, Hsu CC, Jao SW. Clinical entity and treatment strategies for adult intussusceptions: 20 years experience. Simple reduction is reccommended in idiopathic intussusceptions where no pathological underlying lesion is present (36). Adult bowel intussusception is a rare and challenging condition for the surgeon. 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. Intussusception In Adults. official website and that any information you provide is encrypted In this review, we discuss the symptoms, location, etiology, characteristics, diagnostic methods and treatment strategies of this rare and enigmatic clinical entity in adult. For children younger than 2, intussusception is the most common abdominal emergency. Mesenteric fat and blood vessels are barely visible. It can also happen in older children and teenagers. Review of 160 cases. Eisen LK, Cunningham JD, Aufses AH., Jr Intussusception in adults: institutional review. In: StatPearls [Internet]. Adult intussusception in the last 25 years of modern imaging: is surgery still indicated? 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. Certain anatomic features in the developing gastrointestinal tract may predispose the pediatric bowel to an intussusception, including an anterior insertion of the terminal ileum with respect to the cecum, decreased rigidity of the cecum secondary to the absence or underdeveloped taeniae coli, and lack of mature participation of the longitudinal muscle fibers of the colon at the level of the ileocecal valve. Ileal tumors and polyps can cause ileocolic intussusception. The mean age of intussusception in adults is 50 years with no gender predominance. 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. Boudiaf M, Soyer P, Terem C, Pelage JP, Maissiat E, Rymer R. Ct evaluation of small bowel obstruction. Thus, no clear evidence exists on this issue. The child may return to their usual level of activity between bouts, or they may appear listless and lethargic as the pain becomes progressively more intense. In addition, immediate resection is reccommended also in colo-colic intussusception given the high possibility of underlying malignant lesion. Other conditions that predispose to small bowel intussusception include anorexia, nervosa, and malabsorption syndromes, as increased flaccidity of the bowel wall facilitates invagination. A: Ultrasound scan revealed target sign; B and C: Computed tomography scan confirmed ielo-colic intussusception, with no signs of bowel obstruction [orange arrow, horizontal (B) and coronal (C)]. An upper gastrointestinal contrast entero-X-ray may show a "stacked coin" or "coil-spring" appearance, while the lower gastrointestinal contrast entero-X-ray, useful in patients with colic or ileus-colic obstruction, may show a cup-shaped filling defect or spiral or coil-spring appearances[20]. However, it is not usually easy to reduce the intussusception and there is always a high risk of disseminating tumor cells. 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. In the pediatric population, ileocolic intussusception is the most common type. 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. Bar-Ziv J, Solomon A. Computed tomography in 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. Hutchinson J. In contrast, colonic intussusception is more likely to have an underlying malignant lead point (often a colonic adenocarcinoma). Intussusception also cuts off the blood supply to the part of the intestine that's affected. Erbil Y, Eminoglu L, Calis A, Berber E. Ileocolic invagination in adult due to caecal carcinoma. Azar T, Berger DL. 8 Chang CC, Chen YY, Chen YF, Lin CN, Yen HH, Lou HY. The most common site of intussusception was the ileocecal region, reported in 8 (38%) patients. Onkendi EO, Grotz TE, Murray JA, Donohue JH. 10 Independent predictors of malignancy include colonic intussusception and anemia (hemoglobin <12 g/dL). 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. 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. The site is secure. 22 Approach to management of intussusception in adults: a new paradigm in the computed tomography era. Digestive Endoscopy Unit, Hopital Prive Armand Brillard, Nogent-sur-Marne 94130, France. It is reported in literature that the first to operate on a child with intussusception was Sir Jonathan Hutchinson in 1871 (3, 4). However, obesity and the presence of massive air in the distended bowel loops can many times limit the image quality and the diagnostic accuracy of this method (26). Table 3 summarizes recently published case series of adult intussusception regarding presenting symptoms(s), diagnosis, and final pathology. Lloyd D A, Kenny S E. Ontario, Canada: BC Decker; 2004. Despite their rarity, most general and colon and rectal surgeons will treat patients with intussusception, and optimal outcomes will only be achieved by understanding the earlier-outlined principles. Computed tomography (CT) seems to be the most important and sensitive diagnostic method in making a preoperative diagnosis of adult intussusception, especially in patients presented with non-specific abdominal pain (27, 28). The natural history of intussusception starts with a lead point, typically neoplastic (such as lymphadenopathy, polyp, or cancer), which acts as a focal area of traction that draws the proximal bowel within the peristalsing distal bowel. Ratcliffe J F, Fong S, Cheong I, O'Connell P. Plain film diagnosis of intussusception: prevalence of the target sign. Another transient phenomenon is the inverted appendix, which, after ruling out mass lesion by cross-sectional imaging, can often be observed. Nearly half of cases progress to stool mixed with blood and mucus, giving it a currant jelly appearance. Upper gastrointestinal contrast series may show a stacked coin or coil-spring appearance, while a barium enema examination may be useful in patients with colo-colic or ileo-colic intussusception, during which a cup-shaped filling defect or spiral or coil-spring appearances are sometimes characteristically demonstrated (23). Aperistaltic segments may be conceptualized as lead points. The classic triad of intussusception including an abdominal mass, tenderness, and haemoglobin-positive stools is rarely found in adults. 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. Elm'hadi C, Tarchouli M, Khmamouche M R. et al. This condition lead to a transient or permanent bowel obstruction that can evolve even to intestinal ischemia. A 43-year-old male presenting with abdominal pain and vomiting. 15 Instead, it presents with symptoms of small or large bowel obstruction. Adult intussusception; case report of recurrent intussusceptions and review of the literature. See: Department of Endoscopy, "Madonna delle Grazie" Hospital, Matera 75100, Italy; Adult intussusception, Bowel invagination, Bowel obstruction, Computed tomography, Laparoscopic surgery, Endoscopy. Gennaro Nasti, Department of Surgery, "Madonna delle Grazie" Hospital, Matera 75100, Italy. Careers, Unable to load your collection due to an error. The surgical abdomen; p. 604. The CT scan can also demonstrate some pathognomonic radiological aspects as target-like and the sausage-shaped soft tissue mass. 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). The most common locations of intussusception in the gastrointestinal tract are the junctions between freely-moving segments and the retroperitoneal space or segments fixed by adhesions. In the adult population, intussusception is frequently due to a pathologic lead point, which can be intraluminal, mural, or extramural. In a recent systematic review and meta-analysis from Hong et al[12] 1229 adults with intussusception were identified from 40 retrospective case series: Pooled rates of malignant and benign tumors and idiopathic etiologies were 32.9%, 37.4% and 15.1%, respectively. This condition is believed that accounts for less than 0.1% of all adult hospital admissions (7). Three-year surveillance of intussusception in children in Switzerland. Small bowel is more often involved by intussusception rather than large bowel. Other complications may include peritonitis or bowel perforation. It is the most common abdominal emergency in early childhood, particularly in children younger than two years of age [ 1 ]. 9 A causal lesion is identified in 90% of these cases (5, 6). the contents by NLM or the National Institutes of Health. Intussusception in adults: institutional review. Before 9 Notably the ileocolic location in adult intussusception is a variant in which almost the totality of cases has a malignant lead point involving the ileocecal valve[9] (Table (Table22). The most common locations involved in intussusception are at the junctions between mobile and fixed segments of the bowel, such as between the freely-moving ileum and the retroperitoneal cecum. However, the extent of bowel resection and the manipulation of the intussuscepted bowel during reduction remain to be clarified. Intussusception in colorectal cancer. Intussusception - NIDDK - National Institute of Diabetes and Digestive 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. Munden M M, Bruzzi J F, Coley B D, Munden R F. Sonography of pediatric small-bowel intussusception: differentiating surgical from nonsurgical cases. Is believed that in the small bowel, an intussusception can be secondary either to the presence of intra- or extra-luminal lesions such as inflammatory lesions, Meckels diverticulum, postoperative adhesions, lipoma, adenomatous polyps, lymphoma and metastases. National Library of Medicine Wang N, Cui XY, Liu Y, Long J, Xu YH, Guo RX, Guo KJ. Intestinal intussusception in a young women: unusual cause and specific management. In the United States, about 35 to 40 of every 100,000 babies younger than age 1 is hospitalized for intussusception. The diagnosis and treatment of adult intussusception. About 90% of the intussusceptions in adults occur in the small or large bowel, while the remaining 10% involve the stomach or a surgically made stoma. Guilln Paredes M P, Campillo Soto A, Martn Lorenzo J G. et al. Due to the rarity of the left-sides intussusception is recommend to place the two additional 5-mm ports one in the left lower quadrant and the other suprapubically. Fujii Y, Taniguchi N, Itoh K. Intussusception induced by villous tumor of the colon: sonographic findings. Undoubtedly, this procedure requires an appropriate interpretation by an experienced radiologist, in order to establish the diagnosis of intussusception. Ingested food and the subsequent peristaltic activity of the bowel has as result an area of constriction above the stimulus and relaxation below, thus telescoping the lead point through the distal bowel lumen. Takeuchi K, Tsuzuki Y, Ando T, et al. Results: The most common clinical manifestation was abdominal pain, reported in 8 (38%) cases. Azar T, Berger D L. Adult intussusception. The compromised blood flow to the affected segment can cause necrosis of the intestinal wall with bacterial translocation, peritonitis, sepsis and even perforation. Similar to infectious causes, hypertrophy of Peyer patches and/or mesenteric lymphadenopathy can act as a lead point. 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. Adult Intussusception - PMC - National Center for Biotechnology Information 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]. When the small bowel intussusception is induced by malignant lesions these are often metastatic disease (i.e., carcinomatosis). Gayer G, Zissin R, Apter S, et al. Adult intestinal intussusception: CT appearances and identification of a causative lead point. A structural cause was identified in 18 (85.7%) patients, and 17 (81%) patients required surgery. Alonso V, Targarona EM, Bendahan GE, Kobus C, Moya I, Cherichetti C, Balagu C, Vela S, Garriga J, Trias M. Laparoscopic treatment for intussusception of the small intestine in the adult. Benign or malignant neoplasms cause two-thirds of cases with a lead point; the remaining cases are caused by infections, postoperative adhesions, Crohn granulomas, intestinal ulcers (Yersinia), and congenital abnormalities such as Meckel diverticulum. Current surgical therapy. A higher number of lead points is found in young infants and children older than 3 years of age. On this point, we suggest that simple reduction is acceptable in post-traumatic or idiopathic intussusceptions, where no pathological cause could be identified, obviously after the exclusion of bowel ischaemia or perforation, especially in case of small bowel intussusception. government site.

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