intussusception treatment in adults

Factors predicting malignancy in adult intussusception: An experience in university-affiliated hospitals - ScienceDirectWarning: The NCBI website requires JavaScript to operate. Intususception of the intestine in adults: A reviewCorrespondence to: Athanasios Marinis, MD, PhD, Second Department of Surgery, Areteion University Hospital, Athens Medical School, University of Athens, 54 Dimokritou STR, 13673, Acharnes, Athens, Greece. Phone: +30-210-6972335-748Fax: +30-210-2441689AbstractIntussusception of the intestine is defined as the telescopate of a proximal segment of the gastrointestinal tract within the adjoining segment lumen. This condition is common in children and presents the classic triad of abdominal pain, bloody diarrhea and a tender, palpable mass. However, intestinal intususception in adults is considered a rare condition, with 5% of all cases of intussception and almost 1%-5% of intestinal obstruction. Eight to twenty percent of the cases are idiopathic, without an injury to the reference point. Secondary intususception is caused by organic lesions, such as inflammatory bowel disease, postoperative adherents, Meckel diverticulum, benign and malignant lesions, metastatic or even iatrogenic neoplasms, due to the presence of intestinal tubes, jejunostomy feeding tubes or after gastric surgery. Computed tomography is the most sensitive diagnostic modality and can distinguish between intussions with and without a starting point. Surgery is the definitive treatment of adult intusions. The formal resection of the intestine is followed with oncological principles for each case in which malignancy is suspected. The reduction of the intusosecha intestine is considered safe for benign lesions in order to limit the extent of the resection or avoid short intestine syndrome in certain circumstances. INTRODUCTIONFirst reported in 1674 by Barbette of Amsterdam[] and presented in a report detailed in 1789 by John Hunter[] as "introssusception", intususception represents a rare form of intestinal obstruction in the adult, which is defined as the telescopate of a proximal segment of the gastrointestinal tract (GI), called intussusceptum, in the adjacent segment lumenal called Adult intussception accounts for 5 per cent of all cases of intussusception and accounts for only 1 per cent of intestinal obstructions in adults.[] The condition is different from pediatric intususception in various aspects. In children, it is usually primary and benign, and the pneumatic or hydrostatic reduction (air contrast enemas) of intususception is sufficient to treat the condition in 80% of patients. On the other hand, almost 90 per cent of cases of intussusception in adults are secondary to a pathological condition that serves as a starting point, such as carcinomas, polyps, Meckel diverticulum, colon diverticulum, or benign neoplasias, which are usually discovered intraoperatively.[–] Due to a significant risk of associated malignancy, which approximates 65%[,], radiological decompression is not preoperatively addressed in adults. Therefore, between 70 and 90% of cases of adult intususception require a definite treatment, of which surgical resection is more often the treatment of choice.[] MECHANISM-PATHOPHYSIOLOGYIn adults, the exact mechanism of intestinal intussusception is unknown (primary or idiopathic) in 8%-20% of cases and is more likely to occur in the small intestine[,]. On the other hand, it is believed that secondary intususception begins from any pathological lesion of the intestinal or irritating wall within the lumen that alters normal peristaltic activity and serves as a starting point, which is able to initiate an invagation of one segment of the intestine in the other[,]. Esquematically, intususception could be described as an "internal prolapse" of the proximal intestine with its mesentic fold within the adjacent distal intestine lumen as a result of excessive or impaired peristalsis, further obstructing the free passage of the intestinal content and, more severely, compromising the mesential vascular flow of the intussuscepted segment. The result is intestinal obstruction and inflammatory changes ranging from thickening to the ischemia of the intestinal wall. LOCATION-ETILOGY The most common locations in the gastrointestinal tract where intususception can be performed are the unions between freely moving segments and retroperitoneal or adhesionally fixed segments[]. The intusions have been classified according to their locations in four categories: (1) entero-enteric, confined to the small intestine, (2) collo-colic, which implies the large intestine only, (3) ieo-colic, defined as the prolapse of the terminal ileum within the ascending colon and (4) ieo-cecal, where the ileo-cecal valve is the main point of the malignant intussusception[ In the small intestine, an intussusception can be secondary either to the presence of intra-or extra-luminal lesions (inflammatory lesions, Meckel diverticulum, postoperative adhesions, lipoma, adenomatous polyps, lymphoma and metastases) or iatrogens, for example, due to the presence of an intestinal tube[] or even in patients with a gastronomical. Malignity (adenocarcinoma) accounts for up to 30% of cases of intususception occurring in the small intestine[]. A very rare case of our department's experience was a 29-year-old male patient with a diffuse lymphoma of small B cells (such as Burcit) not Hodgkin of the ileum that developed an ieocolic intussception. On the other hand, the intususception that occurs in the large intestine is more likely to have a malignant etiology and represents up to 66% of cases[,]. CLINICA PRESENTATION The clinical presentation of adult intussception varies considerably. The symptoms presented are unspecific and most cases in adults have been reported as chronic, consistent with partial obstruction.[,] The classical pediatric presentation of acute intususception (a triad of abdominal pain, bloody diarrhea and a palpable sensitive mass) is rare in adults. Nausea, vomiting, gastrointestinal bleeding, change of intestinal habits, constipation or abdominal distention are symptoms and non-specific signs of intususception[,]. Intussception in adults can be classified more according to the presence of a point of lead or not[]: transient intussception without a point of lead has been described in spontaneous patients with celia[] or Cronidio On the other hand, intussception with an organic injury as a starting point usually presents as intestinal obstruction, persistent or relapse, requiring, however, a defined surgical therapy. DIAGNOSIS-IMAGINGVariability in clinic presentation and imaging features often make the preoperative diagnosis of intussusception a challenging and difficult task. Reijnen et al[] reported a preoperative diagnosis rate of 50%, while Eisen et al[] reported a lower rate of 40.7%. Flat abdominal films are typically the first diagnostic tool, since in most cases obstructive symptoms dominate the clinical image. These films often show signs of intestinal obstruction and may provide information about the obstruction site[,]. The series of higher gastrointestinal contrasts can show a "sticked body" or "coil-spring" appearance, while a barium enema test can be useful in patients with colo-colic or ieo-colic intussception, during which it is considered a defect of filling "in the form of "occupation" or "spiral" or "coil-spring" is characteristically displayed. The classic characteristics of the image include the "target" or "doughnut" signs in the cross-sectional view and the "pseudo-kidney" or "hay-fork" sign in the longitudinal view[,]. Without a doubt, this procedure requires manipulation and interpretation of an experienced radiologist, to confirm the diagnosis. However, the obesity and the presence of massive air in the neglected intestine loops limit the image quality and the subsequent diagnostic precision. Abdominal computed tomography (CT) is currently considered as the most sensitive radiological method to confirm intussusception, with a diagnostic accuracy reported of 58%-100%[,–]. The characteristics of the CT scan include a "target" or "sausage" in the form of soft tissue mass with a layer effect (Figure); mesentric vessels within the intestinal lumen are also typical.[] A CT scan can define the location, the nature of the mass, its relation to the surrounding tissues, and can also help to statify the patient with suspicion of malignity causing intussception.[] In a recent interesting report by Kim et al[], the abdominal CT was able to distinguish between intususception without a starting point (characteristics: there are no signs of proximal obstruction of the intestine, mass in the form of white or sausage, layer effect) of that with a starting point (characteristics: signs of intestinal obstruction, edema of intestinal wall with loss of the classic appearance of three abdominal layers due to A: The characteristic mass of soft tissue in the form of "target" with a layer effect of a 29-year-old male patient with a diffuse small B cell (such as Burkitt) non-Hodgkin lymphoma of the illiterate that developed an ieo-cholic intussception; B: A mass of soft tissue in the form of "sausage" in the ascending colon of the same patient. DIAGNOSIS-ENDOSCOPYThe flexible endoscopy of the lower GI tract is considered to be inestimable in the assessment of cases of intususception that present with subacuteed or chronic obstruction of the large intestine[]. Confirmation of intususception, location of disease and demonstration of the underlying organic injury that serves as a starting point are the main benefits of endoscopy. The polypectomy of the trap is not recommended in individuals with chronic intussusception presenting with a polypoid mass in the barium or endoscopic examination, due to the high risk of perforation that occurs in a background of ischemia of the chronic tissue and possible necrosis of the wall of the intussuscepted intestine segment[,]. In the case of a lipoma as a starting point for an intussception (Figure ), typical colonoscopic features include a smooth surface, a blade sign or a pillow sign (forced against the injury results in the depression of the mass) and a nude fat sign (fat extrusion during the biopsy)[–]. Collonoscopia. Revealing the presence of the terminal inverted (intussuscept) in the ascending colon (intussuscipiens) in a patient with ieo-cecal intussception due to an ileal lipoma. SURIGIC TREATMENT Due to the fact that adults have acute, under-consistent or non-specific symptoms[], the initial diagnosis is lost or delayed and is established only when the patient is on the operating table (Figure ). Most surgeons agree that adult intususception requires surgical intervention due to the large proportion of structural abnormalities and the high incidence of malignancy. However, the scope of bowel resection and the manipulation of the intussed intestine during the reduction remain controversial.[] In contrast to pediatric patients, where intususception is primary and benign, preoperative reduction with the barium or air is not suggested as a defined treatment for adults[,]. A: Terco terminal eileum, congested and inflated with proximal obstruction of small intestine in a 75-year-old woman with ileo-colonic intussception; B: The surgical specimen after the block resection of the terminal ileum and the ascending colon in the same patient; C: The cause of intussception was a lipoma of the ieo-cecal valve (fleum). The theoretical risks of manipulation and preliminary reduction of an intussuscepted intestine include: (1) intraluminal bending and spread of venous tumor, (2) perforation and bending of microorganisms and tumor cells to the peritoneal cavity and (3) increased risk of anastomotic complications of the manipulated bowel tissue and edematosus[,,,,,,]. In addition, the reduction should not be attempted if there are signs of inflammation or ischemia of the intestinal wall[]. Therefore, in patients with ileo-colic, ieo-cecal and colo-colic intusions, especially those over 60 years of age, due to the high incidence of intestinal malignity as an underlying etiological factor, formal resections are recommended using appropriate oncological techniques, with the construction of a primary anastomosis between healthy and viable tissue[,,,,,,,,,]. Azar et al[] report that, for intusions of the right column, resection and primary anastomosis can be carried out even in unprepared intestines, while for cases on the left side or recsigmoid resection with the construction of a colostomy and a Hartmann bag with re-anastomosis in a second stage is considered safer, especially in the emergency environment. However, when a preoperative diagnosis of a benign lesion is safely established, the surgeon may reduce the intussusception by milking it in a distal to proximal direction[], allowing a limited resection. Wang et al[] report that for enthereal intusions due to benign lesions, limited reduction and resection resulted in the non-repetition of intususception. In patients at risk of short bowel syndrome due to multiple small intestinal polyps that cause intususception, such as Peutz-Jeghers syndrome, a combination approach with limited bowel resection and multi-scaramuzas polypectomy should be mandatory.[] In addition, in complicated patients with intestinal postoperative obstruction due to intususception, reduction is also recommended, provided that the intestine appears non-ischemic and viable.[] Finally, a number of reports have been published on the laparoscopic approach to adult intussusception, due to benign and malignant lesions of the small and large intestine[–]. Laparoscopy has been successfully used in selected cases, depending on the general condition of patients and the availability of surgeons with sufficient laparoscopic experience. After establishing the diagnosis of intususception and the underlying disease laparoscopically, the reduction and/or block resection can be done with the same method. CONCLUSION Adult intestinal intususception is a rare but challenging condition for the surgeon. Preoperative diagnosis is usually lost or delayed due to non-specific and often sub-accused symptoms, without the pathogenic clinical image associated with intussception in children. Abdominal CT is considered the most sensitive imaging modality in the diagnosis of intususception and distinguishes the presence or absence of a reference point. Due to the fact that adult intususception is usually associated with malignant organic lesions, surgery is necessary. Treatment usually requires formal resection of the intestine segment involved. The reduction can be attempted in small intestinal intussions whenever the segment involved is viable or is not suspected of a malignity. Peer reviewer: Luigi Bonavina, Professor, Department of Surgery, Polyclinic San Donato, University of Milano, via Morandi 30, Milano 20097, Italy S- Editor Cheng JX L- Editor Negro F E- Editor Ma WH ReferencesFormats: Share , 8600 Rockville Pike, Bethesda MD, 20894 USA

JavaScript is currently disabled, this site works much better if you enable JavaScript in your browser. *indicates required fields Case reports in GastroenterologySingle Case Intususception in adults: Think of cancer! Hadid T.a,b · Elazzamy H.c · Kafri Z.a, b aDepartment of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USAbDepartment of Internal Medicine, Ascension St. John Hospital, Detroit, MI, USAcGraduate Medical Education, Department of Pathology and Laboratory Medicine, Ascension St. John Hospital, Detroit, MI, USA Tarik Hadid, MD, MPH, MSDepartment of Internal Medicine, Wayne State UniversitySchool of Medicine, 540 E Canfield StreetDetroit, MI 48201 (USA)E-Mail thadid@wayne.edu Keywords: Related articles for "" Intususception in adults: Think of cancer! Tarik Hadid, MD, MPH, MSDepartment of Internal Medicine, Wayne State UniversitySchool of Medicine, 540 E Canfield StreetDetroit, MI 48201 (USA)E-Mail thadid@wayne.eduKeywords: Related Articles for "ResumenIntususception is a rare phenomenon in adults and usually presents with intestinal obstruction. Unlike childhood intususception, adult intususception is rarely idiopathic and is often associated with secondary causes such as benign and malignant tumors. While most cases are treated surgically, emerging data suggest a more conservative approach to management for patients with short-segment adult intussusception and without high-risk features such as intestinal obstruction, mass imaging, colon involvement or constitutional symptoms of malignancy. We present a rare case of adult intususception due to non-supposed adenocarcinoma of the jejune, successfully treated with surgical resection followed by adjuvant chemotherapy. We favor the surgical approach rather than conservative for adult patients with intussception to avoid unsuspecting malignant tumors that are not easily visualized in imaging studies.© 2020 The author(s). Published by S. Karger AG, Basel IntroductionThe intususception of the towel represents a rare type of intestinal obstruction and is defined as telescoping the proximal loop of the intestine (intussusceptum) within the distal loop (intussuscipiens), which results in the obliteration of the lumen [, ]. While it is commonly found in children, adult intususception (AI) is extraordinarily rare, with an estimated incidence of 2 cases/1,000,000 population/year [, ]. Childhood intussception is commonly idiopathic (primary) with most cases related to the ileum but may rarely involve the stomach, colon, and the rest of the small intestine. It occurs more commonly in male children between 4 and 10 months old [, , ]. Curiously, the tetravalent rotavirus vaccine is associated with a slightly higher risk of intususception among vaccinated children (1.5 cases of excess per 100,000) []. On the other hand, AI is associated with underlying pathology (secondary) in 90% of cases and equally affects men and women [, ]. AI is presented in the small intestine in 52% of cases and the large intestine in 38% with 10% involving the stomach and surgical stomach [, ]. The clinical symptoms of AI are variable and often not specific. Patients may have diffuse abdominal pain, nausea, vomiting, blood feces, changes in bowel habits and/or abdominal distended. The clinical test may reveal abdominal discontinuation or diffuse abdominal tenderness, but often does not show any anomaly. The ambiguity of these clinical findings and their similarity with many other more common conditions such as inflammatory bowel diseases, intestinal obstruction due to peritoneal adhesions, and infectious gastroenteritis make the clinical diagnosis of the AI quite challenging. Diagnosing AI requires a high suspicion rate, which often requires the use of imaging studies such as computerized tomography (CT) []. It should be noted that the generalized medical use of CT has increased the preoperative diagnosis rate of AI []. While more than 80% of cases in children can be reduced with hydrostatic enemas, most cases of AI require surgical intervention [, , ]. Untreated intususception can be life-threatening, starting with progressive intestinal distention, which in turn produces an increase in intralumec pressure, which eventually leads to microvascular ischemia, thysular necrosis with subsequent intestinal perforation, and peritonitis []. Therefore, early diagnosis and treatment of AI are critical to avoid these complications. In this report, we present a case of AI due to the underlying malignant jejunal neoplasm that was effectively diagnosed and treated. We also discuss some of the diagnostic procedures and therapeutic interventions used in the management of the AI. Case presentationA 69-year-old non-diabetic female presented with altered mental state, nausea, vomiting and diffuse abdominal discomfort for 3 days. He did not report hematochezia or melena, but he admitted poor appetite and 20 pounds of weight loss in the last 6 months. His past medical history was positive for atrial fibrillation, rheumatoid arthritis, chronic obstructive pulmonary disease and hyperthyroidism. He had a history of iron deficiency anemia for 2 years with hemoglobin nadir of 7.4. Esophagogastroduodenoscopia and colonoscopy performed 2 years before the presentation did not reveal any source of bleeding. The patient was treated with oral iron supplement with hemoglobin enhancement at 11.7. I had no previous abdominal surgery. It smoked 5 to 9 cigarettes a day for more than 20 years but denied drinking alcohol or using illicit drugs. He didn't report a family history of malignity. The test revealed blood pressure of 139/70, pulse of 91/min, temperature of 97.6°F, oxygen saturation of 100% in the room air, and weight of 120 pounds. Your head and neck exam revealed mild exophthalmos without cervical or supraclavicular lymphadenopathy. Pulmonary and heart tests were normal. The abdomen was moderately neglected with diffuse tenderness, and its limbs had no edema. In the presentation, the complete blood count (CBC) showed a white blood cell count of 5,100/μL, hemoglobin of 8.4 g/dL, average corpuscular volume of 81.9 fl and platelet count of 172,000/μ L. CBC 1 year earlier showed hemoglobin of 10 g/dL. When admitted, it was found that it had glucose of 41 mg/dL (secondary only to decrease oral intake), which was successfully treated by intravenous dextrose. After improving the mental state and administration of proper hydration, a CT scan of the abdomen and pelvis was performed and high-grade intestinal obstruction was revealed due to the intususception of small intestine (Fig. ). A transition point was identified in the media-pelvis, but no mass could be seen. Laparotomy confirmed intususception (Fig. ), and 10 cm of the mid-jejune were resected. Moderately differentiated, invasive 5 cm invasive adenocarcinoma with focal areas of necrosis (Fig. ). There was no evidence of lymphedical invasion. All surgical margins were negative, and only one in three resected lymph nodes was positive. A CT scan of the chest did not reveal evidence of metastatic disease. It was staged as T3N1M0 (phase III). After recovering from the operation, he received 12 cycles of adjuvant chemotherapy with 5-fluorouracil, leucovorina and oxaliplatin, which tolerated well. Repeating computed tomography after the termination of therapy did not reveal evidence of recurrence. Repeating CBC was normal with hemoglobin of 14.1 g/dL. She's still alive without disease evidence 2 years after the initial presentation. TC of the pelvis showing small intestinal intususception. Operating image showing intususception of the jejune. Hematoxylin and stained section of resected jejunium eosin that shows malignant cells forming gland, consistent with adenocarcinoma (magnification ×40). Debate AI is a rare clinical entity with potential for serious complications if not recognized and treated quickly. It is often classified on the basis of its location to entero-enteric (confined to the small intestine), colo-colic (confined to the large intestine), ieo-colic (when the terminal ileum is submerged to the ascending colon), and ieo-cecal (when the ileo-cecal valve is the main point of intussception) []. It can also be classified based on its etiology for benign, malignant and idiopathic. More than 90% of pediatric cases are idiopathic []. The hypertrophy of lymph tissues in the terminal ileum, known as the Peyer patch, is thought of the main point of intussception in children and can be triggered by viral infections []. On the other hand, the etiology of the AI includes carcinoma, Meckel diverticulum, colon diverticulum, lymphoma, lipoma, rigures, metastatic lesions, polyps or inflammatory lesions. Adenocarcinoma accounts for 30% of all intusions of small adult intestines and 66% of colonic intususions [, ].The classic presentation of childhood intususception, which includes the triad of coconut abdominal pain, rantin stool and a flexible abdominal mass in the form of sausage, is rarely found in adults. Most patients have symptoms and signs of intestinal obstruction. Although symptoms usually occur acutely, they may be under- or chronic, especially in colon intususception. In children, the abdominal ultrasound provides a rapid and sensitive screening test for intussception and can reveal the "doughnuts' sign" and the "pseudo-kidney apparition" []. In adults, it was found that computed tomography was more accurate []. In a study, it was reported that the diagnostic accuracy of computed tomography was almost 100% [, ]. The appearance of TC usually includes a "object", "yellow of the wrist", or sausage-shaped lesions. Alternatively, it was found that ultrasound was less reliable in adults, due to intestinal edema, airflow levels and larger fecal charges []. The treatment modalities for intususception are variable. Because ieo-colic is the most common type seen in children, the reduction is often successful by using pneumatic or hydrostatic edema. In addition, integer-enteric intusions generally reduce spontaneously. Alternatively, AI is treated historically surgically. Random clinical trials are missing that compare operational and non-cooperative approaches to AI. However, a recent study suggested that up to 82% of radiological intusions can be treated safely and successfully. However, this approach should be used with great caution to prevent potentially serious underlying conditions such as malignancy. The operational approach is necessary in patients with intestinal obstruction, those with mass view by image, those with constitutional symptoms of malignancy (such as weight loss, anorexia, night sweating, etc.), and those with colobolic and ieocholic intussception (due to their superior association with malignity) []. Adults with integer-enteric intusions shorter than 3.5 cm and without any of the above features are often self-limiting and can be considered for non-operational management []. Our patient was treated surgically, as he presented a small bowel obstruction and had a significant weight loss (14% of his body weight); both were related to underlying malignancy. When surgery is performed, intususception should be surgically reduced in children and resected in adults. If it is suspected that there is underlying malignancy, the oncological resection in the block of the involved intestine and associated mesentry should be sought. In colobolic intusions, preoperative colonoscopy may be useful in identifying underlying pathology and may help in appropriate surgery planning. However, colon biopsy should be performed with caution due to the increased risk of perforation due to tissue ischemia []. The IA prognosis depends to a large extent on the underlying pathology. If malignity is found, appropriate antineoplastic therapy should be instituted postoperatively if clinically indicated. In conclusion, AI can be a manifestation of serious conditions such as malignancy. While conservative management was proposed in low-risk patients, we favor the surgical approach to avoid potentially curable malignancy as in our patient. Oncology surgery and subsequent antineoplastic therapy should be used to make these patients optimise clinical outcomes. Ethical Statement The patient provided written consent for publication. He was provided with a copy of the manuscript. Dissemination Statement All authors reveal that they do not have conflicts of interest related to this study. Sources of funding The authors received no funding. Author's contributions Tarik Hadid, MD, MPH, MS, obtained the patient's consent, patient care, collected the patient's data, revised the literature, wrote the initial draft of the manuscript, and revised the later versions. Haidy Elazzamy, MD, reviewed the pathology of the resected specimen, prepared the pathological figure for the manuscript, and revised and edited the manuscript. Zyad Kafri, MD, MS, revised, edited and supervised the process of building the manuscript to its final version. Related Articles:References Author ContactsTarik Hadid, MD, MPH, MSDepartment of Internal Medicine, Wayne State UniversitySchool of Medicine, 540 E Canfield StreetDetroit, MI 48201 (USA)E-Mail thadid@wayne.eduArticle/Publication Details Received: November 03, 2019 Accepted: December 17, 2019 Published online: January 20, 2020 Date of publication: January - April Number of printing pages: 7 Number of figures: 3 Number of tables: 0 eISSN: (Online) For additional information: Open Access License / Drug Dosage / Exemption This article is licensed under the Creative Commons Attribution-NoCommercial 4.0 International License (CC BY-NC). Use and distribution for commercial purposes requires written permission. Drug Dosage: The authors and the editor have made every effort to ensure that the selection and dosage of drugs set out in this text are in accordance with current recommendations and practices at the time of publication. However, in view of the ongoing investigation, changes in government regulations and the steady flow of information concerning drug therapy and drug reactions, the reader is urged to review the insert of packages for each drug for any change in indications and doses and for additional warnings and precautions. This is particularly important when the recommended agent is a new medication and/or employee infrequently. Disclaimer: The statements, opinions and data contained in this publication are only those of the authors and individual collaborators and not of the editors and editors. The appearance of advertisements or/and product references in the publication is not a guarantee, approval or approval of the products or services announced or their effectiveness, quality or safety. The editor and the editor(s) claim liability for any damage to persons or property resulting from any idea, method, instructions or products to which the content or advertisements relates. 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