Adult intussusception Gabi Gayer Assaf Harofeh Medical Center, Israel AFIIM 2008

Adult intussusception Occurs infrequently Differs from childhood intussusception in: Incidence Presentation Etiology Treatment

Adult and childhood intussusceptions Children Adult % of all intussusceptions 95 5 Cause of obstruction Frequent Rare Etiology Idiopathic 90% 10-30% Identifiable cause 10% 70–90% Clinical symptoms Classic triad Non specific Treatment Mainly non-operative Surgical

Mechanism Lesion in the bowel wall or Irritant within the bowel lumen may alter the normal peristaltic pattern => starting an invagination leading to intussusception

Pathophysiology of Intussusception Kim YH. et al. Radiographics 2006;26:733-744

Clinical findings Age: second - ninth decade Mean age ~ 50 years Male = Female

Symptoms and signs Abdominal pain Nausea Vomiting Constipation Bleeding per rectum Diarrhea Abdominal mass Fever

Symptoms and signs Acute – rare! Intermittent Chronic => making preoperative diagnosis difficult

Classification of Intussusception Location enteroenteric ileocolic ileocecal colocolic

Classification of Intussusception Lead point (90%?) Neoplastic ~ 65% benign malignant Non neoplastic ~ 35% No lead point (10%?)

Lead point (90%) Neoplastic ~ 65% Benign Hamartoma- Peutz-Jehger polyp Lipoma Leiomyoma Malignant Adenocarcinoma Lymphoma Leiomyosarcoma Metastases

Lead point (90%) Non Neoplastic ~ 35% Meckels' diverticulum Adhesions Celiac disease Intestinal duplication Henoch-Schonlein purpura Infection (AIDS patients)

Lead point according to location Small bowel Benign > Malignant Hamartoma- Peutz-Jehger polyp Lipoma Leiomyoma Metastases - melanoma Colon Malignant > Benign Adenocarcinoma Lymphoma

CT the most useful radiological modality Imaging - CT CT the most useful radiological modality

CT Findings Typical bowel-within-bowel appearance Thickened segment of bowel containing an eccentric crescent-like fatty area representing intussusception & mesentery

CT Findings Depending on the angle of the CT beam vs. the intussusception Oblong sausage-shaped mass Round target mass Crescent: fatty mesentery

58 y old man abdominal pain, weight loss suspected acute bowel obstruction

Left hemicolectomy Pathology: Adenocarcinoma

72-year-old man with metastatic non small cell lung carcinoma s/p chemotherapy treatment

72-year-old man with metastatic NSCLC 5 week history of intermittent, increasingly frequent, upper abdominal pain Work up included upper and lower endoscopy notable only for some gastritis  Abdominal ultrasound and CT

5 week intermittent upper abdominal pain

5 week intermittent upper abdominal pain

Surgery: Resection of jejunum Intussusception in proximal half of the jejunum The bowel proximal to intussusception was moderately dilated and distally it was decompressed  The site of intussusception markedly thickened Multiple large mesenteric nodes up to ~ 3 cm in diameter No evidence of metastatic disease within liver/ peritoneum No additional intra-abdominal pathology was identified Pathology: Melanoma

Lead point = obstruction? NO

24y old man intermittent abdominal pain

24y old man intermittent abdominal pain

24y old man intermittent abdominal pain

Right hemicolectomy Pathology: Burkitt Lymphoma

56-y male with previously recurrent mantle cell lymphoma Mantle cell lymphoma cervical and oropharyngeal involvement 10/2002  Treated chemotherapy & radiation therapy Complete response for 2 years Recurrence in the rectum and gastric body 2005 Partial response to treatment

56-y male with previously recurrent mantle cell lymphoma Presenting 8/07 with fever 101.1 Right lower quadrant pain - worsening “Of note, he has complained of chronic right lower quadrant pain for the past two months” Tenderness to palpation in right midabdomen a palpable ~ 5 cm long mass Lab: neutropenia

56-y male with previously recurrent mantle cell lymphoma

Surgery and pathology Right hemicolectomy Ileocolic intussusception related to recurrent mantle cell involvement

65-y right lower quadrant pain 65-year-old woman presented to the ER with several days of increasing right lower quadrant pain, nausea and vomiting Endoscopy revealed some gastritis

65-y right lower quadrant pain

Surgery Rt hemicolectomy Ileocecal intussusception An exophytic, fungating, 5 x 3 cm mass located in the cecum Adenocarcinoma, poorly differentiated Lymph Node Status: uninvolved, 0/35

Can we characterize the underlying lead point? Often not, but sometimes!

39y old man intermittent abdominal pain

Right hemicolectomy Pathology: Lipoma 5 cm causing ileo-colic intussusception

26-y-old woman with rectal bleeding Symptoms for 2 months: Rectal bleeding Mucus discharge Constipation Tenesmus Grandmother with rectal cancer at age 33 Colonoscopy: a rectal mass Biopsy: adenocarcinoma

26-y-old woman with rectal adeno Ca

26-y-old woman with rectal adenocarcinoma

47 year old woman vague history of Crohn's disease

Surgery: Resection of 50cm of SB

Pathology: Small bowel wall with areas of hemorrhagic necrosis of mucosa only, consistent with ischemia, probably due to intussusception No granulomas identified

Transient small bowel intussusception Intussusception may be transient Intussusception detected on imaging but not confirmed by surgery but does not appear on a repeat study

Transient small bowel intussusception Transient intussusception observed on SB barium follow-through studies in patients with adult celiac disease * Mechanism: loss of normal tone in the small bowel induced by the toxic effect of gluten * Transient small bowel intussusception in adult coeliac disease. Cohen MD, Lintott DJ. Clinical Radiology 1978

Transient small bowel intussusception The growing use of CT for abdominal imaging => increased detection of transient intussusceptions with no underlying disease

Transient small bowel intussusception Fresh diagnostic challenge Need to distinguish features of self-limiting small-bowel intussusception identified at CT

Transient small bowel intussusception Retrospective review intussusception on CT or MR 33 patients with intussusception 8 years Location 29 patients had enteroenteric intussusceptions 4 intussusceptions involving the colon Etiology 10 patients (30%) had a neoplastic lead point 23 patients (70%) no neoplastic lead point - variety of causes Warshauer DM et al. Radiology 1999;212:853-60

Transient small bowel intussusception ~ 1/3 of cases were caused by a neoplastic lead point About half of adult cases in this series were idiopathic Enteric intussusceptions in the nonneoplastic group Length - shorter (median, 4 vs 10.8 cm) Diameter - smaller (median, 3 vs 4 cm) Less likely to be associated with obstruction (4% vs 50%) Warshauer DM et al. Radiology 1999;212:853-60

Transient small bowel intussusception Intussusception with a neoplastic lead point compared to nonneoplastic ones significantly longer significantly larger diameter significantly more common proximal dilatation of SB Warshauer DM et al. . Radiology 1999;212:853-60

Transient small bowel intussusception Retrospective study: To determine if clinical or CT findings can be used to distinguish self-limiting cases of adult small-bowel intussusception from those requiring surgery Lvoff N et al. Radiology 2003; 227:68–72

Transient small bowel intussusception Retrospective computerized search of 69,040 abdominopelvic CT 4-year period 37 (0.05%) cases of adult SB intussusception 6 patients (16%) underwent surgery, all had lead-point tumors (most mets) 31 patients (84%) treated conservatively none required surgery Lvoff N et al. Radiology 2003; 227:68–72

Distinguishing features of self-limiting transient SB intussusception Intussusception length of 3.5 cm All 20 patients with intussusception length of <=3.5cm self-limiting 17 patients had an intussusception length > 3.5 cm 11 patients intussusception self-limiting 6 patients intussusception required surgery Lvoff N et al, Radiology 2003;227:68-72

Distinguishing features of self-limiting transient SB intussusception Intussusception length The main factor in distinguishing the majority of small-bowel intussusceptions detected with CT that are self-limiting from the minority that require surgery An intussusception that is less than 3.5 cm in length is likely to be self-limiting Lvoff N et al, Radiology 2003;227:68-72

Transient small bowel intussusception 79 y old man following ERCP

Elderly lady breast Ca

Delayed scan

Elderly lady breast Ca

Transient small bowel intussusception 33-year-old man Precontrast scan

Postcontrast scan

Transient small bowel intussusception 33-year-old man Postcontrast scan

Transient small bowel intussusception 79 y old man following ERCP

Transient small bowel intussusception 80-year-old woman Postcontrast scan

Transient small bowel intussusception Attributed to minor transient disturbances in bowel motility without clinical importance More common in the proximal small bowel, where peristaltic activity is normally greater

Transient small bowel intussusception Most of these cases would not have come to attention were it not for CT being performed to evaluate unrelated disease or symptoms

Transient small bowel intussusception Transient intussusceptions are, however, not necessarily idiopathic and may occur either with or without a pathological lead point

Transient small bowel intussusception No lead point Lead point

Lead point- self limiting Pathologic process acting as lead point Adult celiac sprue Crohn’s disease Eosinophilic enteritis Intestinal lymphoid hyperplasia – infections allergic response to various foods

Crohn’s disease

Barium follow through next day

Transient small bowel intussusception 45y old male with melanoma

Transient small bowel intussusception 45y old male with melanoma

Transient small bowel intussusception 45y old male with melanoma

Melanoma and SB intussusception Dramatically increasing incidence of malignant melanoma, not infrequently late recurrence Unusual presentations of late gastrointestinal recurrence can be expected

Melanoma and SB intussusception Melanoma is well known for its capricious clinical course in terms of metastatic behavior Melanoma shows an unusual predilection for metastasizing to small bowel A long interval between removal of primary tumor and development of metastasis

Melanoma and SB intussusception Metastasis of malignant melanoma to the GI tract: 50%–60% of autopsy cases Only 2% to 5% of patients with such metastases are diagnosed while they are alive This is due to the fact that symptoms of early development are not specific but general and constitutional

Melanoma and SB intussusception Metastasis to GI tract is seen most frequently in the small intestine, followed by colon, stomach, and rectum, but rare in esophagus Primary malignant melanoma originating in the small intestine is extremely rare

Melanoma and SB intussusception Symptoms of SB metastasis of melanoma: chronic GI blood loss, obstruction, abdominal pain, anorexia, nausea, vomiting, weight loss Time interval between identification of melanoma and diagnosis of GI metastasis: 2 - 180 months Aggressive surgical resection is controversial regarding its effect on prognosis

Treatment Not the role of the radiologist DO NOT REDUCE! Radiologist’s role: guiding treatment Differentiating the type of intussusception

Intussusception without Lead Point Transient, Spontaneously resolving No bowel obstruction =>No treatment required Intussusception with Lead Point Persistent or recurrent Bowel obstruction => Surgery required

Treatment Transient- no intervention However If a tumor suspected - surgical resection

Treatment Resection of the intussusception without reduction is the preferred treatment, as about half of both colonic and enteric intussusceptions are associated with malignancy

Adult Intussusception Rare Pathognomonic CT features Underlying pathology – sometimes Small bowel, short segment – consider transient intussusception Colo-colic – consider malignancy

MERCI Thank you

CT Findings Oral contrast: Rim-shaped accumulation of contrast material in the periphery of the mass

CT Findings Per rectum contrast: Rim of contrast encircling the intussusceptum, analogous to the coil spring seen in enema

The basic facts 5% of all intussusceptions occur in adults Account for 1% of all bowel obstructions Fact ? 70%–90% of cases have a demonstrable cause based on discharge diagnosis or surgical results

Etiology of Intussusception The etiology of intussusception in the small bowel and the colon is quite different

Small Bowel Intussusception: Etiology Benign lesions -Majority Benign neoplasms (lipoma, leiomyoma, hemangioma, neurofibroma) Adhesions Meckel diverticulum Lymphoid hyperplasia and adenitis Trauma Celiac disease Intestinal duplication Henoch-Schonlein purpura

Small Bowel Intussusception: Etiology Malignant lesions (15% of cases) Metastatic, melanoma most common metastasis to cause intussusception Idiopathic intussusception 20%??

Colon Intussusception: Etiology Malignant etiology (50%-60%) adenocarcinoma lymphoma Benign lesions (30%) lipoma, leiomyoma, adenomatous polyp, endometriosis, previous anastomosis. Idiopathic intussusception (~ 10%) Less often than in the small bowel

26-y-old woman with rectal adeno Ca

26-y-old woman with rectal adeno Ca

A feeding tube inserted via jejunostomy A 22-year-old man with a head injury

Intussusception following surgery for abdominal trauma 21 patients after trauma operated for intestinal obstruction Six (29%) intussusception cause of obstruction All males, ages 17 - 25 years Mechanisms of injury gunshot wounds 3 stab wounds 2 blunt trauma 1 Duncan A et al. Intussusception following abdominal. J Trauma. 1987;27:1193-9.

Intussusception following surgery for abdominal trauma Interval surgery intussusception First 8 postoperative days – 4 patients 21 days – 1 patient 10 months – 1 patient Jejunojejunal intussusception - 5 patients Jejunoileal -1 Duncan A et al. Intussusception following abdominal. J Trauma. 1987;27:1193-9.

Intussusception following surgery for abdominal trauma Increased incidence of postoperative SB obstructions is caused by intussusception in trauma patients Duncan A et al. Intussusception following abdominal. J Trauma. 1987;27:1193-9.