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

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

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

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

5. Pathophysiology of Intussusception
Kim YH. et al. Radiographics 2006;26:

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

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

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

9. Classification of Intussusception
Location
enteroenteric
ileocolic
ileocecal
colocolic

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

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

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

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

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

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

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

17. 58 y old man abdominal pain, weight loss suspected acute bowel obstruction

20. Left hemicolectomy Pathology: Adenocarcinoma

21. 72-year-old man with metastatic non small cell lung carcinoma s/p chemotherapy treatment

22. 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

23. 5 week intermittent upper abdominal pain

24. 5 week intermittent upper abdominal pain

25. 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

26. Lead point = obstruction?NO

27. 24y old man intermittent abdominal pain

28. 24y old man intermittent abdominal pain

29. 24y old man intermittent abdominal pain

30. Right hemicolectomy Pathology: Burkitt Lymphoma

31. 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

32. 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

33. 56-y male with previously recurrent mantle cell lymphoma

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

36. 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

37. 65-y right lower quadrant pain

39. 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

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

41. 39y old man intermittent abdominal pain

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

46. 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

47. 26-y-old woman with rectal adeno Ca

48. 26-y-old woman with rectal adenocarcinoma

49. 47 year old woman vague history of Crohn's disease

51. Surgery: Resection of 50cm of SB

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

53. 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

54. 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

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

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

57. 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

58. 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

59. 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

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

61. 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

62. 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

63. 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

64. Transient small bowel intussusception 79 y old man following ERCP

65. Elderly lady breast Ca

66. Delayed scan

67. Elderly lady breast Ca

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

70. Postcontrast scan

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

72. Transient small bowel intussusception 79 y old man following ERCP

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

75. 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

76. 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

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

78. Transient small bowel intussusception
No lead point
Lead point

79. 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

80. Crohn’s disease

81. Barium follow through next day

82. Transient small bowel intussusception 45y old male with melanoma

83. Transient small bowel intussusception 45y old male with melanoma

84. Transient small bowel intussusception 45y old male with melanoma

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

86. 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

87. 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

88. 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

89. 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:
months
Aggressive surgical resection is controversial regarding its effect on prognosis

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

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

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

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

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

95. MERCI
Thank you

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

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

98. 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

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

100. 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

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

102. 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

103. 26-y-old woman with rectal adeno Ca

104. 26-y-old woman with rectal adeno Ca

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

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

110. 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:

111. 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: