Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
Adult Adult IntussusceptionIntussusception
Sherry Sherry FarzanFarzan--KashaniKashani, HMS III, HMS III
Gillian Lieberman, MDGillian Lieberman, MD
Core Radiology RotationCore Radiology Rotation
August 2003August 2003
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
22
What is What is IntussusceptionIntussusception??
Telescoping of proximal Telescoping of proximal
segment segment
((intussusceptumintussusceptum)) of GI of GI
tract into an adjacent and tract into an adjacent and
distal one distal one
((intussuscepiensintussuscepiens))
Commonly seen in Commonly seen in
pediatric population as pediatric population as
ileocolicileocolic w/o identifiable w/o identifiable
lesion (95%)lesion (95%)
Rare cause of obstruction Rare cause of obstruction
in adults w/ identifiable in adults w/ identifiable
lesion (5%)lesion (5%)
www.pedisurg.comwww.pedisurg.com
intussusceptum
intussuscepiens
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
33
What Happens Next?What Happens Next?
As As intussusceptumintussusceptum
telescopes into telescopes into
intussuscepiensintussuscepiens, ,
mesentery containing mesentery containing
vascular components is vascular components is
trapped between the two trapped between the two
layers of bowellayers of bowel
Vascular compression Vascular compression
bowel edema bowel edema
further further
vascular compression vascular compression
ischemic necrosis ischemic necrosis
peritonitis, aberrant airperitonitis, aberrant air
Courtesy of Dr. Wendy Durgin
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
44
Gross PathologyGross Pathology
Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed p 2119-2120.
On the left, the intussusceptum has become ischemic. On the right, opening the
outer layer reveals the telescoping of the intussusceptum.
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Patient R.S.Patient R.S.
CC: 25yo male with bilateral upper quadrant CC: 25yo male with bilateral upper quadrant
““needleneedle--likelike”” pain; presented at clinicpain; presented at clinic
PMH:PMH:
s/ps/p orthotopicorthotopic liver transplant one year ago for liver transplant one year ago for
fulminantfulminant liver failureliver failure
RouxRoux--enen--Y Y hepaticojejunostomyhepaticojejunostomy
Hepatic artery Hepatic artery stentingstenting five five
months agomonths ago
Admitted for GI series workAdmitted for GI series work--upup
www.danaise.com
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
66
Patient R.S.Patient R.S.
PE @ BIDMCPE @ BIDMC
No acute distressNo acute distress
Abdomen soft and Abdomen soft and nondistendednondistended
Bilateral upper quadrant tenderness without Bilateral upper quadrant tenderness without
rebound or guardingrebound or guarding
Otherwise unremarkableOtherwise unremarkable
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Differential DiagnosisDifferential Diagnosis
Organ Rejection/ThrombosisOrgan Rejection/Thrombosis
AdhesionsAdhesions
Bowel ObstructionBowel Obstruction
IntussusceptionIntussusception
Abdominal HerniaAbdominal Hernia
Abdominal MassAbdominal Mass
GI BleedGI Bleed
CholecystitisCholecystitis
ConstipationConstipation
UlcerUlcer
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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CTA of LiverCTA of Liver
Lead Point
Mesenteric vessels
Dilated proximal
jejunal loop with
debris
BIDMC Radiology Department
Liver
Kidneys Aorta
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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CTA of LiverCTA of Liver
mesenteric
vessels
BIDMC Radiology Department
Target Lesion
intussuscepiens
intussusceptum
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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CTA of LiverCTA of Liver
BIDMC Radiology Department
intussusceptum
intussuscepiens
mesenteric
vessels
Sausage lesion
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Oblique ReconstructionOblique Reconstruction
intussusceptiens
intussusceptumEnhancing
mesenteric
vessels
BIDMC Radiology Department
Surgical
staples
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Delayed ImagingDelayed Imaging
BIDMC Radiology Department
Intussusception
has resolved
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
1313
Barium Swallow with Small Bowel Barium Swallow with Small Bowel
Follow ThroughFollow Through
Filling defect
consistent with
intussucepted
small bowel
BIDMC Radiology Department
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
1414
Intermittent PropulsionIntermittent Propulsion
BIDMC Radiology Department BIDMC Radiology Department
In real time, the intussusceptum moved in and out of the intussuscepiens.
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Diagnosis for Patient R.S.Diagnosis for Patient R.S.
Chronic transient Chronic transient intussusceptionintussusception
Surgical sutures within Surgical sutures within intussusceptionintussusception
suggest involvement as lead point suggest involvement as lead point
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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IntussusceptionIntussusception
Adults vs. ChildrenAdults vs. Children
1% of all adult bowel 1% of all adult bowel
obstxnobstxn (only 53 cases @ (only 53 cases @
MGH btw 1964MGH btw 1964--19931993
5% of all 5% of all intussusceptionintussusception
Demonstrable etiology in Demonstrable etiology in
7070--90% 90%
Acute, intermittent, or Acute, intermittent, or
chronic (chronic (““acute abdomenacute abdomen””
is rareis rare
Enteric, Enteric, ileocolicileocolic, ,
ileocecalileocecal, colonic, colonic
Surgical resection Surgical resection
22ndnd most common most common
abdominal emergency in abdominal emergency in
childrenchildren
95% of all 95% of all
intussusceptionintussusception
Usually no demonstrable Usually no demonstrable
etiologyetiology
Acute presentationAcute presentation
IleocolicIleocolic
NonNon--operative reductionoperative reduction
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Signs & Symptoms in AdultsSigns & Symptoms in Adults
Intermittent/chronic Intermittent/chronic abdominal pain (70abdominal pain (70--90%)90%)
VomittingVomitting/Nausea (80%)/Nausea (80%)
Red blood per rectum (30%)Red blood per rectum (30%)
Abdominal distension/ Abdominal distension/ shiftingshifting mass (10mass (10--40%)40%)
Weight loss (10%)Weight loss (10%)
Fever (10%)Fever (10%)
Chronic constipation or diarrhea (<10%)Chronic constipation or diarrhea (<10%)
Acute (24hr), intermittent, and chronic (5yr)Acute (24hr), intermittent, and chronic (5yr)
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Etiology in AdultsEtiology in Adults
NeoplasticNeoplastic ProcessProcess
NonNon--NeoplasticNeoplastic ProcessProcess
Idiopathic ProcessIdiopathic Process
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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NeoplasticNeoplastic IntussusceptionIntussusception
BenignBenign
LipomaLipoma
AdenomatousAdenomatous polyppolyp
MeckelMeckel’’ss DiverticulumDiverticulum
HamartomatousHamartomatous polyppolyp
HemangiomaHemangioma
LeiomyomaLeiomyoma
NeurofibromaNeurofibroma
Malignant Malignant
Primary Primary –– adenoCAadenoCA, , leiomyosarcomaleiomyosarcoma, , carcinoidcarcinoid, lymphoma, , lymphoma,
KaposiKaposi’’ss
Metastatic Metastatic –– melanoma, lymphoma, sarcomamelanoma, lymphoma, sarcoma
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
2020
NonNon--NeoplasticNeoplastic & Idiopathic & Idiopathic
IntussusceptionIntussusception
NonNon--NeoplasticNeoplastic
PostPost--Op: Adhesions, suture lines, edema, Op: Adhesions, suture lines, edema, dysmotilitydysmotility
Inflammatory lesions: Inflammatory lesions: CrohnCrohn’’ss, lymphoid hyperplasia , lymphoid hyperplasia
(AIDS)(AIDS)
Disordered motilityDisordered motility
May be permanent or transientMay be permanent or transient
IdiopathicIdiopathic –– no etiology foundno etiology found
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PathophysiologyPathophysiology
Lead point seen in >90% of casesLead point seen in >90% of cases
Primarily in small bowelPrimarily in small bowel
JJ--J, IJ, I--I, II, I--Co, ICo, I--CeCe, S, S--R, R, CeCe--CoCo
PeristalsisPeristalsis
Peristalsis and ingested food push Peristalsis and ingested food push intussusceptumintussusceptum
into relaxed and distal into relaxed and distal intussuscipiensintussuscipiens
Tends to occur at Tends to occur at jnxjnx of free bowel and of free bowel and
retroperitoneal/fixed segments (e.g. retroperitoneal/fixed segments (e.g. ileoileo--cecalcecal))
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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PostPost--Surgical Surgical IntussusceptionIntussusception
50% of benign intussusceptions50% of benign intussusceptions
Complication of RouxComplication of Roux--enen--Y limbsY limbs
Retrograde Retrograde intussusceptionintussusception (anti(anti--peristaltic) peristaltic)
through Rouxthrough Roux--enen--Y Y anastomosisanastomosis
RouxRoux--enen--Y stasis syndromeY stasis syndrome
Lead point may be suture line or adhesionLead point may be suture line or adhesion
Reduction without resection is reasonable Reduction without resection is reasonable
if bowel is viableif bowel is viable
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Transient Transient IntussusceptionIntussusception
Completely resolved on Completely resolved on f/uf/u examsexams
Accounts for many of nonAccounts for many of non--neoplasticneoplastic cases cases
Commonly seen in Celiac Disease (20%)Commonly seen in Celiac Disease (20%)
Loss of normal tone in small bowel due to toxic Loss of normal tone in small bowel due to toxic
effects of gluteneffects of gluten
Flaccid loops are more susceptible to Flaccid loops are more susceptible to intussusceptionintussusception
Diarrheal diseases w/ abnormal bowel motilityDiarrheal diseases w/ abnormal bowel motility
Increasingly seen because of CT scansIncreasingly seen because of CT scans
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Management of Transient Management of Transient
IntussusceptionIntussusception
Younger pts w/ smaller, shorter intussusceptionsYounger pts w/ smaller, shorter intussusceptions
length of <3.5cm on CT was independently predictive length of <3.5cm on CT was independently predictive
of transienceof transience
Likely nonLikely non--neoplasticneoplastic
These pts treated conservatively and did not have These pts treated conservatively and did not have
recurrence at recurrence at f/uf/u > 100days> 100days
Questionable clinical significance; possibly Questionable clinical significance; possibly
physiologicalphysiological
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Diagnostic ProceduresDiagnostic Procedures
Plain Abdominal FilmsPlain Abdominal Films
Upper GI Series Upper GI Series
Barium EnemaBarium Enema
UltrasoundUltrasound
CTCT
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Plain Abdominal FilmsPlain Abdominal Films
May see airMay see air--fluid levels in fluid levels in
dilated bowel loops if dilated bowel loops if
obstruction is sufficientobstruction is sufficient
Meniscus sign (leading Meniscus sign (leading
edge of edge of intussusceptumintussusceptum))
0% accuracy in adults in 0% accuracy in adults in
one studyone study
Used to R/O free air prior Used to R/O free air prior
to enema reductionto enema reduction
Daneman et al. Pediatr Radiol 2003; 33: 79-85
Soft tissue
abdominal
mass
Meniscus
sign
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Upper GI Series and Small Bowel Upper GI Series and Small Bowel
Follow ThroughFollow Through
Bowel within bowelBowel within bowel
Filling defect Filling defect
indicating obstructionindicating obstruction
Accuracy of 21% in Accuracy of 21% in
adults in one studyadults in one study
Possibly therapeutic Possibly therapeutic
when when invaginationinvagination
compressed compressed
BIDMC Radiology Dept
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Barium EnemaBarium Enema
Cup shaped filling Cup shaped filling
defect defect
Coil spring Coil spring
Accuracy of 54% in Accuracy of 54% in
adults in one studyadults in one study
Contraindicated if Contraindicated if
suspected bowel suspected bowel
perforation or perforation or
ischemiaischemia
Coil Spring
appearance
Cup-Shaped
Filling Defect
Matsuba Y et al. J Gastroenterol. 2003;38(2):181-5
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Air EnemaAir Enema
intussusceptum
www.uptodate.com
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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UltrasonographyUltrasonography
Modality of choice in Modality of choice in
pediatricspediatrics
Transverse view Transverse view ––
target/donut signtarget/donut sign
Longitudinal view Longitudinal view ––
pseudokidneypseudokidney/ sandwich / sandwich
signsign
Limited by Limited by
presence of air in bowel presence of air in bowel
poor transmissionpoor transmission
Operator dependentOperator dependent
Grainger & Allison's Diagnostic RadiologyA Textbook of Medical
Imaging, 4th Ed., p1214-1216.
Daneman et al. Pediatr Radiol 2003; 33: 79-85
Transverse view
Longitudinal view
Sherry Farzan-Kashani, HMS III
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CTCT
Early Early –– target target lzlz or oblong or oblong
sausage shaped masssausage shaped mass
Later Later –– layering effectlayering effect
Finally Finally –– amorphous massamorphous mass
Presence of these signs is Presence of these signs is
pathognomicpathognomic
+/+/-- dilation and dilation and obstxnobstxn
Most accurate Most accurate –– 78% 78% DxDx
in adultsin adults
Can identify other Can identify other
pathologypathology
Non-Contrast CT, Transverse view
Oral Contrast CT, Longitudinal view
Ko et al. World J. World J. SurgSurg 2002; 26: 4382002; 26: 438––443443
Haas et al. Haas et al. Am J Am J SurgSurg 2003; 186(1): 752003; 186(1): 75--7676
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Treatment in AdultsTreatment in Adults
Surgical ResectionSurgical Resection
Caused by neoplasm in up to 50% of casesCaused by neoplasm in up to 50% of cases
Colon Colon
en bloc en bloc resxnresxn b/cb/c hi likelihood of neoplasmhi likelihood of neoplasm
Small Bowel Small Bowel
initial initial redxnredxn then then resxnresxn if not if not
neoplasticneoplastic or or infarctedinfarcted
Selective Selective adhesionolysisadhesionolysis, , diverticuletomydiverticuletomy, ,
polypectomypolypectomy w/o w/o resxnresxn is alternative in small bowel is alternative in small bowel
casescases
With surgery, there is a low incidence of recurrenceWith surgery, there is a low incidence of recurrence
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Treatment in AdultsTreatment in Adults
Reduction via colonoscopy, Reduction via colonoscopy, insufflationinsufflation
Conservative Conservative TxTx reserved for those lesions known to reserved for those lesions known to
be benign (e.g. be benign (e.g. lipomalipoma))
W/o surgery, hi risk of recurrenceW/o surgery, hi risk of recurrence
Transient Transient intussusceptionintussusception resolves on its ownresolves on its own
May not need therapeuticsMay not need therapeutics
Chronic transient Chronic transient intussusceptionintussusception –– Patient R.S.Patient R.S.
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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Back to our Patient R.S.Back to our Patient R.S.
Patient remained in hospital for five daysPatient remained in hospital for five days
Sent home because in stable conditionSent home because in stable condition
Decided to have surgical procedure as Decided to have surgical procedure as
outpatient to correct chronic and outpatient to correct chronic and
symptomatic symptomatic intussusceptionintussusception
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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SummarySummary
IntussusceptionIntussusception is a rare, yet serious condition is a rare, yet serious condition
in adultsin adults
May be a marker of pathological lesionMay be a marker of pathological lesion
Increase use of CT causing increased pickIncrease use of CT causing increased pick--up of up of
transient transient intussusceptionintussusception
CT scan is most accurate method of CT scan is most accurate method of DxDx
Visualization is ideal because of nonVisualization is ideal because of non--specific signs and specific signs and
symptomssymptoms
Target lesion on axial viewTarget lesion on axial view
Sausage shaped lesion on longitudinal viewSausage shaped lesion on longitudinal view
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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AcknowledgementsAcknowledgements
Thank you to Dr. Kane for suggesting the index Thank you to Dr. Kane for suggesting the index
case and to Dr. case and to Dr. StienStien for his help in interpreting for his help in interpreting
the films.the films.
Thank you to Pamela Thank you to Pamela LepkowskiLepkowski for her for her
technical help.technical help.
Thank you to Dr. Gillian Lieberman for her Thank you to Dr. Gillian Lieberman for her
teaching and guidance.teaching and guidance.
Thank you to Larry Thank you to Larry BarbarbasBarbarbas, our Webmaster., our Webmaster.
Sherry Farzan-Kashani, HMS III
Gillian Lieberman, MD
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ReferencesReferences
AzarAzar T, Berger DL. Adult T, Berger DL. Adult IntussusceptionIntussusception. . Ann of Ann of SurgSurg 1997; 226(2):1341997; 226(2):134--138.138.
BegosBegos DG, DG, SandorSandor A, A, ModlinModlin IM. The Diagnosis and Management of Adult IM. The Diagnosis and Management of Adult
IntussusceptionIntussusception. . Am J Am J SurgSurg 1997; 173: 881997; 173: 88--94. 94.
DanemanDaneman A, Navarro O. A, Navarro O. IntussusceptionIntussusception. . PediatrPediatr RadiolRadiol 2003; 33:792003; 33:79--85.85.
Feldman: Feldman: SleisengerSleisenger & & FordtranFordtran’’ss Gastrointestinal and Liver Disease, 7Gastrointestinal and Liver Disease, 7thth eded; p 2119; p 2119--
2120.2120.
Gayer G, Gayer G, ApterApter S, Hofmann C, S, Hofmann C, NassNass S, S, AmitaiAmitai M, M, ZissinZissin R, Hertz M. R, Hertz M. IntussusceptionIntussusception in in
Adults: CT Diagnosis. Adults: CT Diagnosis. Clinical RadiologyClinical Radiology 1998; 53: 531998; 53: 53--57.57.
Gayer, G, Gayer, G, ZissinZissin R, R, ApterApter S, Papa M, Hertz M. Adult S, Papa M, Hertz M. Adult IntussusceptionIntussusception –– a CT Diagnosis. a CT Diagnosis.
Br J Br J RadiolRadiol 2002; 75(890): 1852002; 75(890): 185--190.190.
Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th Ed.,
p1214-1216.
Haas EM, Haas EM, EtterEtter EL, Ellis S, Taylor TV. Adult EL, Ellis S, Taylor TV. Adult intussusception.intussusception.A