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Athanasios Marinis, Anneza Yiallourou, Lazaros Samanides, Nikolaos Dafnios, Georgios Anastasopoulos,
Ioannis Vassiliou, Theodosios Theodosopoulos
Athanasios Marinis, Anneza Yiallourou, Lazaros Samanides, Adult; Bowel obstruction; Computed tomography; Ultra-
Nikolaos Dafnios, Georgios Anastasopoulos, Ioannis sonography; Surgery
Vassiliou, Theodosios Theodosopoulos, Second Department
of Surgery, Areteion University Hospital, Athens Medical School, Peer reviewer: Luigi Bonavina, Professor, Department of
University of Athens, 76 Vassilisis Sofias Ave., 11528, Athens, Surgery, Policlinico San Donato, University of Milano, via
Greece Morandi 30, Milano 20097, Italy
Author contributions: Marinis A and Yiallourou A wrote the
paper; Theodosopoulos T and Samanides L contributed equally in Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastaso-
this work; Dafnios N and Anastasopoulos G gathered referenced
poulos G, Vassiliou I, Theodosopoulos T. Intussusception of
data and contributed equally in organizing them; Vassiliou I,
Samanides L and Theodosopoulos T reviewed the paper. the bowel in adults: A review. World J Gastroenterol 2009;
Correspondence to: Athanasios Marinis, MD, PhD, Second 15(4): 407-411 Available from: URL: http://www.wjgnet.
Department of Surgery, Areteion University Hospital, Athens com/1007-9327/15/407.asp DOI: http://dx.doi.org/10.3748/
Medical School, University of Athens, 54 Dimokritou STR, wjg.15.407
13673, Acharnes, Athens, Greece. drmarinis@gmail.com
Telephone: +30-210-6972335-748 Fax: +30-210-2441689
Received: July 29, 2008 Revised: August 6, 2008
Accepted: August 13, 2008 INTRODUCTION
Published online: January 28, 2009
First reported in 1674 by Barbette of Amsterdam[1] and
further presented in a detailed report in 1789 by John
Hunter[2] as introssusception, intussusception represents
Abstract a rare form of bowel obstruction in the adult, which is
defined as the telescoping of a proximal segment of the
Intussusception of the bowel is defined as the telescop- gastrointestinal (GI) tract, called intussusceptum, into the
ing of a proximal segment of the gastrointestinal tract lumen of the adjacent distal segment of the GI tract, called
within the lumen of the adjacent segment. This condi- intussuscipiens. Historically, Sir Jonathan Hutchinson
tion is frequent in children and presents with the classic was the first to operate on a child with intussusception in
triad of cramping abdominal pain, bloody diarrhea and a 1871[3].
palpable tender mass. However, bowel intussusception in Adult intussusception represents 5% of all cases of
adults is considered a rare condition, accounting for 5%
intussusception and accounts for only 1%-5% of intestinal
of all cases of intussusceptions and almost 1%-5% of
obstructions in adults[4]. The condition is distinct from
bowel obstruction. Eight to twenty percent of cases are
pediatric intussusception in various aspects. In children, it
idiopathic, without a lead point lesion. Secondary intus-
is usually primary and benign, and pneumatic or hydrostatic
susception is caused by organic lesions, such as inflam-
matory bowel disease, postoperative adhesions, Meckels
(air contrast enemas) reduction of the intussusception is
diverticulum, benign and malignant lesions, metastatic sufficient to treat the condition in 80% of the patients.
neoplasms or even iatrogenically, due to the presence of In contrast, almost 90% of the cases of intussusception
intestinal tubes, jejunostomy feeding tubes or after gas- in adults are secondary to a pathologic condition that
tric surgery. Computed tomography is the most sensitive serves as a lead point, such as carcinomas, polyps, Meckels
diagnostic modality and can distinguish between intus- diverticulum, colonic diverticulum, strictures or benign
susceptions with and without a lead point. Surgery is the neoplasms, which are usually discovered intraoperatively[5-7].
definitive treatment of adult intussusceptions. Formal Due to a significant risk of associated malignancy, which
bowel resection with oncological principles is followed for approximates 65%[8,9], radiologic decompression is not
every case where a malignancy is suspected. Reduction addressed preoperatively in adults. Therefore, 70 to
of the intussuscepted bowel is considered safe for benign 90% of adult cases of intussusception require definite
lesions in order to limit the extent of resection or to avoid treatment, of which surgical resection is, most often, the
the short bowel syndrome in certain circumstances. treatment of choice[10].
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Marinis A et al . Adult intussusception 409
A B C
Figure 3 Intraoperative findings. A: Thickened, congested and inflamed terminal ileum with proximal small bowel obstruction in a 75-year old woman with ileo-
colonic intussusception; B: The surgical specimen after the en bloc resection of the terminal ileum and the ascending colon in the same patient; C: The cause of the
intussusception was a lipoma of the ileo-cecal valve (arrow).
impaired mesenteric circulation and demonstration of in depression of the mass) and the naked fat sign (fat
the lead mass), and this may help reducing the number extrusion during biopsy)[36-38].
of unnecessary surgical interventions.
SURIGICAL TREATMENT
DIAGNOSIS-ENDOSCOPY Due to the fact that adults present with acute, subacute,
Flexible endoscopy of the lower GI tract is considered or chronic nonspecific symptoms[9], the initial diagnosis
invaluable in evaluating cases of intussusception presenting is missed or delayed and is established only when the pa-
with subacute or chronic large bowel obstruction [10]. tient is on the operating table (Figure 3). Most surgeons
Confirmation of the intussusception, localization of the accept that adult intussusception requires surgical inter-
disease and demonstration of the underlying organic lesion vention because of the large proportion of structural
serving as a lead point are the main benefits of endoscopy. anomalies and the high incidence of occurring malignan-
Snare polypectomy is not advisable in individuals with cy. However, the extent of bowel resection and the ma-
chronic intussusception presenting with a polypoid mass nipulation of the intussuscepted bowel during reduction
on barium or endoscopic examination, due to the high risk remain controversial[10]. In contrast to pediatric patients,
of perforation occurring in a background of chronic tissue where intussusception is primary and benign, preopera-
ischemia and possible necrosis of the intussuscepted bowel tive reduction with barium or air is not suggested as a
segments wall[34,35]. In the case of a lipoma as a lead point definite treatment for adults[10,17,39].
of an intussusception (Figure 2), typical colonoscopic The theoretical risks of preliminary manipulation
features include a smooth surface, the cushion sign or and reduction of an intussuscepted bowel include: (1)
pillow sign (forcing the forceps against the lesion results intraluminal seeding and venous tumor dissemination,
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(2) perforation and seeding of microorganisms and intussusceptions provided that the segment involved is
tumor cells to the peritoneal cavity and (3) increased viable or a malignancy is not suspected.
risk of anastomotic complications of the manipulated
friable and edematous bowel tissue[4,5,10,17,22]. Moreover,
reduction should not be attempted if there are signs of REFERENCES
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