1. Joint Hospital Grand Round Topic : Adult Intussusception Dr. Eric Lai Department of Surgery Prince of Wales Hospital

2. Adult Intussusception Uncommon surgical condition in adult 5 % of all intussusception 1% of causes of Intestinal obstruction 0.003 % to 0.02 % of all hospital admissions was caused by intussusception. First case was reported in 1674

3. Adult Intussusception 70 % to 90 % of cases are secondary to a definable lesion, while the opposite is true in children Especially in colonic type of intussusception, it was highly associated with malignancy

4. Symptoms Most diagnosis was delayed and not made before laparotomy. Nonspecific Acute, chronic ( most common ), acute on chronic Pain ( most common ) – periodic, intermittent nature ( most important characteristics ) Vomiting Red blood per rectum

5. Signs Abdominal mass Identification of a shifting mass, or one which is only palpable when symptoms are present, is particularly suspicious of an intussusception

6. Investigation For patient with obstructive symptoms AXR : differentiate the site of obstruction Contrast study : Cup shaped filling defect, may accompanied by an additional filling defect representing the leading tumour

7. Investigation For patient suspected to have intussusception USG AbdomenUSG Abdomen usually used to evaluate suspected intussusception. non-invasive, cheap and easily available. The classic features of intussusception include the “target ” and “dognut” signs in the transverse view and the “pseudokidney” sign in the longitudinal view.

8. Investigation CT Scan AbdomenCT Scan Abdomen CT scan was advocated by some series to be the most useful and accurate investigation for suspected intussusception It gives the characteristic target sign or sausage- shaped appearance

9. Management for Colonic Intussusception The likelihood of neoplasm is high in colonic intussusception. Up to two-third of the colonic intussusception was associated with primary carcinoma. Operative management is thus almost always necessary

10. Management for Colonic Intussusception Reduction prior Resection ? Resection without Reduction ?

11. Management for Colonic Intussusception According to present literature, most authors advocate primary surgical resection without prior attempt of reduction Intussusception involve Rt colonIntussusception involve Rt colon Rt / extended Rt hemicolectomy Intussusception involve Lt colonIntussusception involve Lt colon Lt hemicolectomy Sigmoid-rectal IntussusceptionSigmoid-rectal Intussusception Need careful assessment of the rectum first Anterior resection / AP resection

12. Causes Against Prior Reduction Intraluminal seeding or venous embolization of malignant cells during operative manipulation Focal area of mucosal necrosis, which might have extended beyond the margins of an adequate resection if reduction had been performed before resection

13. Management for Small Bowel Intussusception In the patient with small bowel intussusception, 6 % - 30 % of cases are associated with malignancy. Majority of these malignancies are metastasis rather than primary malignant lesion. Most of the small bowel intussusceptions have benign causes other than malignancy, e.g. adhesion, benign tumour, polyps.

14. Management for Small Bowel Intussusception Initial gentle reduction, followed by limited surgical resection, is preferred treatment. Treatment should be individualized according to each clinical situation.

15. Thank you