adult intussusception gabi gayer assaf harofeh medical center, israel afiim 2008

Adult intussusceptionAdult intussusception

Gabi GayerGabi Gayer

Assaf Harofeh Medical Center, Assaf Harofeh Medical Center, IsraelIsrael

AFIIM 2008AFIIM 2008

Adult intussusception

• Occurs infrequently

• Differs from childhood intussusception in:

Incidence

Presentation

Etiology

Treatment

Adult and childhood intussusceptionsAdult and childhood intussusceptions

Children Children Adult Adult

% of all intussusceptions% of all intussusceptions 95 95 5 5

Cause of obstructionCause of obstruction FrequentFrequent Rare Rare

EtiologyEtiology IdiopathicIdiopathic 90% 90%

10-30%10-30% Identifiable causeIdentifiable cause 10% 10% 70–90% 70–90%

Clinical symptomsClinical symptoms Classic triad Non specificClassic triad Non specific

TreatmentTreatment Mainly non-operative Surgical 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

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

Pathophysiology of IntussusceptionPathophysiology of Intussusception

Clinical findingsClinical findings

• Age: second - ninth decade Age: second - ninth decade

Mean age ~ 50 yearsMean age ~ 50 years

• Male = FemaleMale = Female

Symptoms and signsSymptoms and signs

• Abdominal pain

• Nausea

• Vomiting

• Constipation

• Bleeding per rectum

• Diarrhea

• Abdominal mass

• Fever

Symptoms and signsSymptoms and signs

• Acute – rare!Acute – rare!

• IntermittentIntermittent

• Chronic Chronic

=> making preoperative diagnosis difficult => making preoperative diagnosis difficult

Classification of Intussusception

LocationLocation

enteroentericenteroenteric

ileocolicileocolic

ileocecalileocecal

colocoliccolocolic

Classification of Intussusception

Lead point (90%?)Lead point (90%?)

NeoplasticNeoplastic ~ 65%~ 65%

benignbenign

malignantmalignant

Non neoplastic ~ 35%Non neoplastic ~ 35%

No lead point (10%?)No lead point (10%?)

Lead point (90%)• Neoplastic ~ 65%Neoplastic ~ 65%

Benign Hamartoma- Peutz-Jehger polypLipomaLeiomyoma

Malignant AdenocarcinomaLymphomaLeiomyosarcomaMetastases

Lead point (90%)

• Non Neoplastic ~ 35%Non Neoplastic ~ 35%

Meckels' diverticulumMeckels' diverticulum

AdhesionsAdhesions

Celiac diseaseCeliac disease

Intestinal duplicationIntestinal duplication

Henoch-Schonlein purpuraHenoch-Schonlein purpura

Infection (AIDS patients) Infection (AIDS patients)

Lead point according to locationLead point according to location• Small bowelSmall bowel

Benign > MalignantBenign > MalignantHamartoma- Peutz-Jehger polypHamartoma- Peutz-Jehger polyp

LipomaLipoma

Leiomyoma Leiomyoma

Metastases - melanomaMetastases - melanoma

• ColonColon Malignant > Benign Malignant > Benign

AdenocarcinomaAdenocarcinoma

Lymphoma Lymphoma

Imaging - CTImaging - CT

CT the most useful radiological modalityCT the most useful radiological modality

CT Findings

Typical bowel-within-bowel appearanceTypical bowel-within-bowel appearance

Thickened segment of bowel containing an Thickened segment of bowel containing an

eccentric crescent-like fatty area eccentric crescent-like fatty area

representing intussusception & mesenteryrepresenting intussusception & mesentery

CT Findings

Depending on the angle of the CT beam Depending on the angle of the CT beam

vs. the intussusceptionvs. the intussusception

• Oblong sausage-shaped mass Oblong sausage-shaped mass

• Round target mass Round target mass

• Crescent: fatty mesenteryCrescent: fatty mesentery

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

Left hemicolectomyLeft hemicolectomy

Pathology: Adenocarcinoma

72-year-old man with metastatic non small cell lung carcinomas/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

Surgery: Resection of jejunumSurgery: 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: MelanomaPathology: Melanoma

• Lead point = obstruction?

NO

24y old man intermittent abdominal pain

Right hemicolectomyRight hemicolectomy

Pathology: Burkitt LymphomaPathology: 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



• 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 midabdomena palpable ~ 5 cm long mass

• Lab: neutropenia

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 65-year-old woman presented to the ER

with several days of increasing right lowerwith several days of increasing right lower

quadrant pain, nausea and vomiting quadrant pain, nausea and vomiting

• Endoscopy revealed some gastritis Endoscopy revealed some gastritis

6565--y right lower quadrant painy right lower quadrant pain

SurgerySurgery

• Rt hemicolectomyRt hemicolectomy

• Ileocecal intussusceptionIleocecal intussusception

• An exophytic, fungating, 5 x 3 cm mass An exophytic, fungating, 5 x 3 cm mass

located in the cecum located in the cecum

• Adenocarcinoma, poorly differentiatedAdenocarcinoma, poorly differentiated

• Lymph Node Status: uninvolved, 0/35 Lymph Node Status: uninvolved, 0/35

Can we characterize the underlying Can we characterize the underlying

lead point?lead point?

Often not, but sometimes!

39y old man intermittent abdominal pain

Right hemicolectomyRight hemicolectomy Pathology: Lipoma 5 cmPathology: Lipoma 5 cm

causing ileo-colic intussusceptioncausing 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 with26-y-old woman withrectal adenocarcinomarectal 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 transientIntussusception may be transient

• Intussusception detected on imaging Intussusception detected on imaging

but not confirmed by surgerybut not confirmed by surgery

• Intussusception detected on imaging Intussusception detected on imaging

but does not appear on a repeat studybut does not appear on a repeat study

Transient small bowel intussusceptionTransient 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


The growing use of CT for abdominal imaging

=> increased detection of transient

intussusceptions with no underlying disease


Fresh diagnostic challenge

Need to distinguish features of self-limitingNeed to distinguish features of self-limiting

small-bowel intussusception identified at CTsmall-bowel intussusception identified at CT


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;212:853-60Warshauer DM et al. Radiology 1999;212:853-60


~ 1/3 of cases were caused by a neoplastic lead point~ 1/3 of cases were caused by a neoplastic lead point

About half of adult cases in this series were idiopathicAbout half of adult cases in this series were idiopathic

Enteric intussusceptions in the nonneoplastic groupEnteric intussusceptions in the nonneoplastic group

• Length - Length - shortershorter (median, 4 vs 10.8 cm) (median, 4 vs 10.8 cm)

• Diameter - Diameter - smallersmaller (median, 3 vs 4 cm) (median, 3 vs 4 cm)

• Less likely to be associated with obstruction (4% vs 50%)Less likely to be associated with obstruction (4% vs 50%)

Warshauer DM et al. Radiology 1999;212:853-60Warshauer DM et al. Radiology 1999;212:853-60


Intussusception with a neoplastic lead pointIntussusception with a neoplastic lead pointcompared to nonneoplastic onescompared to nonneoplastic ones

• significantly longer significantly longer

• significantly larger diametersignificantly larger diameter

• significantly more common proximal dilatation of SB

Warshauer DM et al. . Radiology 1999;212:853-60Warshauer DM et al. . Radiology 1999;212:853-60


RetrospectiveRetrospective 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; 227:68–72Lvoff N et al. Radiology 2003; 227:68–72


• 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; 227:68–72Lvoff N et al. Radiology 2003; 227:68–72

Distinguishing features of self-limiting Distinguishing features of self-limiting transient SB intussusceptiontransient 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 Distinguishing features of self-limiting transient SB intussusceptiontransient 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


79 y old man following ERCP

Elderly lady breast CaElderly lady breast Ca

Delayed scan

Elderly lady breast CaElderly lady breast Ca


33-year-old man

Precontrast scan

Postcontrast scan


33-year-old man

Postcontrast scan


79 y old man following ERCP


80-year-old woman Postcontrast scan


• Attributed to Attributed to minor transient disturbances in

bowel motility without clinical importance

• More common in the proximal small bowel, More common in the proximal small bowel,

where peristaltic activity is normally greaterwhere peristaltic activity is normally greater


Most of these cases would not have come to

attention were it not for CT being performed

to evaluate unrelated disease or symptoms


Transient intussusceptions are, however,

not necessarily idiopathic and may occur

either with or without a pathological

lead point


• No lead point

• Lead point

Lead point- self limitingLead point- self limiting

Pathologic process acting as lead pointPathologic process acting as lead point

• Adult celiac sprue Adult celiac sprue

• Crohn’s diseaseCrohn’s disease

• Eosinophilic enteritisEosinophilic enteritis

• Intestinal lymphoid hyperplasia –Intestinal lymphoid hyperplasia –

– infections infections

– allergic response to various foods allergic response to various foods

Crohn’s disease

Barium follow through next dayBarium follow through next day


45y old male with melanoma45y old male with melanoma

Melanoma and SB intussusceptionMelanoma and SB intussusception

• Dramatically increasing incidence of Dramatically increasing incidence of

malignant melanoma, not infrequently late malignant melanoma, not infrequently late

recurrence recurrence

• Unusual presentations of late Unusual presentations of late

gastrointestinal recurrence can be gastrointestinal recurrence can be

expectedexpected


• Melanoma is well known for its capricious Melanoma is well known for its capricious

clinical course in terms of metastatic clinical course in terms of metastatic

behavior behavior

• Melanoma shows an unusual predilection for Melanoma shows an unusual predilection for

metastasizing to small bowelmetastasizing to small bowel

• A long interval between removal of primary A long interval between removal of primary

tumor and development of metastasistumor and development of metastasis


• Metastasis of malignant melanoma to the GI Metastasis of malignant melanoma to the GI

tract: 50%–60% of autopsy casestract: 50%–60% of autopsy cases

• Only 2% to 5% of patients with such Only 2% to 5% of patients with such

metastases are diagnosed while they are alive metastases are diagnosed while they are alive

• This is due to the fact that symptoms of early This is due to the fact that symptoms of early

development are not specific but general and development are not specific but general and

constitutionalconstitutional


• 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


• 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

TreatmentTreatment

Not the role of the radiologist

DO NOT REDUCE!DO NOT REDUCE!

Radiologist’s role: guiding treatment Radiologist’s role: guiding treatment

Differentiating the type of intussusceptionDifferentiating the type of intussusception

Intussusception without Intussusception without

Lead PointLead Point

• Transient, Transient,

Spontaneously resolvingSpontaneously resolving• No bowel obstructionNo bowel obstruction

=>No treatment required=>No treatment required

Intussusception with Intussusception with

Lead PointLead Point

• Persistent or recurrentPersistent or recurrent

• Bowel obstructionBowel obstruction

=> Surgery required=> 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

MERCIMERCI

Thank youThank you

CT Findings

• Oral contrast:Oral contrast:

Rim-shaped accumulation of contrastRim-shaped accumulation of contrast

material in the periphery of the massmaterial in the periphery of the mass

CT Findings• Per rectum contrast: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 lesions -Majority Benign neoplasms Benign neoplasms (lipoma, leiomyoma, hemangioma, neurofibroma)(lipoma, leiomyoma, hemangioma, neurofibroma)

AdhesionsAdhesionsMeckel diverticulumMeckel diverticulumLymphoid hyperplasia and adenitisLymphoid hyperplasia and adenitis

TraumaTraumaCeliac diseaseCeliac diseaseIntestinal duplicationIntestinal duplicationHenoch-Schonlein purpura Henoch-Schonlein purpura

Small Bowel Intussusception: Etiology

Malignant lesions (15% of cases)Malignant lesions (15% of cases)

• Metastatic, melanoma most common metastasis to cause intussusception

Idiopathic intussusceptionIdiopathic 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

A feeding tube inserted via jejunostomyA feeding tube inserted via jejunostomy

A 22-year-old man with a head injuryA 22-year-old man with a head injury

http://bjr.birjournals.org/content/vol75/issue890/images/large/BI76270.4.5.jpeg

Intussusception following surgery Intussusception following surgery for abdominal traumafor abdominal trauma

21 patients after trauma operated for intestinal 21 patients after trauma operated for intestinal

obstruction obstruction

Six (29%) intussusception cause of obstruction Six (29%) intussusception cause of obstruction

All males, ages 17 - 25 years All males, ages 17 - 25 years

Mechanisms of injury Mechanisms of injury

gunshot wounds 3gunshot wounds 3

stab wounds 2stab wounds 2

blunt trauma 1blunt trauma 1 Duncan A et al. Intussusception following abdominal. J Trauma. 1987;27:1193-9.Duncan A et al. Intussusception following abdominal. J Trauma. 1987;27:1193-9.


Interval surgery intussusception Interval surgery intussusception

First 8 postoperative days – 4 patientsFirst 8 postoperative days – 4 patients

21 days – 1 patient21 days – 1 patient

10 months – 1 patient10 months – 1 patient

Jejunojejunal intussusception - 5 patientsJejunojejunal intussusception - 5 patients

Jejunoileal -1Jejunoileal -1

Duncan A et al. Intussusception following abdominal. J Trauma. 1987;27:1193-9.Duncan A et al. Intussusception following abdominal. J Trauma. 1987;27:1193-9.


Increased incidence of postoperative SBIncreased incidence of postoperative SB

obstructions is caused by intussusceptionobstructions is caused by intussusception

in trauma patients in trauma patients

Duncan A et al. Intussusception following abdominal.Duncan A et al. Intussusception following abdominal.

J Trauma. 1987;27:1193-9.J Trauma. 1987;27:1193-9.

adult intussusception gabi gayer assaf harofeh medical center, israel afiim 2008

Documents

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