Intussusception is the most common cause of bowel obstruction in infants and children. Although early recurrence is not uncommon, recurrence years later is rare.
A 13-year-old male with a history of recurrent intussusception at ages 2 and 5 presented with recurrent intussusception 8 years later. The diagnosis was made using computed tomography, and the patient underwent a laparoscopic ileocecectomy with an uneventful postoperative course.
The specimen was remarkable for findings of multiple enlarged lymph nodes over the serosal surface of the ileum and the terminal ileum with focal edema, prominent lymphoid hyperplasia and large hemorrhagic areas.
This case highlights the fact that in a child with a delayed recurrence of intussusception, the presence of a lead point should be suspected, and operative therapy should be strongly considered over hydrostatic reduction. The current management of recurrent intussusception is reviewed and applied to this case.
This report presents the case of a 37-year-old man with multiple Emergency Department visits for abdominal pain and with negative results for prior imaging studies, who was eventually diagnosed with intussusception after 5 years of recurrent symptoms. The case is followed by a review of the literature.
Recurrent abdominal pain is a common and challenging presenting chief complaint in the Emergency Department. Intussusception in adults, although rare, is an important etiology to consider. The diagnosis can often be delayed because of the nonspecific and intermittent nature of symptoms in adults. This report presents the case of a 37-year-old man with multiple Emergency Department visits for abdominal pain and with negative results for prior imaging studies, who was eventually diagnosed with intussusception after 5 years of recurrent symptoms. The case study is followed by a review of the literature regarding the diagnosis and management of intussusception in adults.
We report a case of adult intussusception caused by cecal adenocarcinoma that was treated by laparoscopy-assisted ileocecal resection following reduction by contrast enema and preoperative colonoscopy. A 68-year-old male with cecal cancer was admitted to our hospital because of colicky abdominal pain after taking a laxative. His abdomen was distended, and a mass was palpable in the right upper quadrant, which appeared as a target- or sausage-shaped lesion by ultrasonograhpy and computed tomography. A contrast enema using water-soluble material showed a cup-shaped filling defect characterized by intussusception in the ascending colon. This round defect with a clear margin was pushed gradually back into the cecum by the enema pressure. Re-occurrence of the intussusception is easily released by colonoscopy. We performed laparoscopy-assisted ileocecal resection of a protruding tumor measuring 6.5 cm × 5.0 cm × 3.5 cm from the cecum, with D3 lymph node dissection. Histological examination revealed a well-differentiated adenocarcinoma that had invaded the serosa without permeating the lymphatic or venous capillaries, as well as lymph node metastasis. The postoperative course was uneventful, and the patient has been well without evidence of disease recurrence for 5 years following the operation. Preliminary reduction of adult colonic intussusception before surgical resection is therefore an option in cases of an early and correct diagnosis of intussusception.
Adult intussusception; Cecal cancer; Enema reduction; Colonoscopy; Laparoscopy-assisted surgery
To describe the sonographic (US) and clinical features of spontaneously reduced small bowel intussusception, and to discuss the management options for small bowel intussusception based on US findings with clinical correlation.
Materials and Methods
During a five years of period, 34 small bowel intussusceptions were diagnosed on US in 32 infants and children. The clinical presentations and imaging findings of the patients were reviewed.
The clinical presentations included abdominal pain or irritability (n = 25), vomiting (n = 5), diarrhea (n = 3), bloody stool (n = 1), and abdominal distension (n = 1), in combination or alone. US showed multi-layered round masses of small (mean, 1.5±0.3 cm) diameters and with thin (mean, 3.5±1 mm) outer rims along the course of the small bowel. The mean length was 1.8±0.5 cm and peristalsis was seen on the video records. There were no visible lead points. The vascular flow signal appeared on color Doppler images in all 21 patients examined. Spontaneous reduction was confirmed by combinations of US (n = 28), small bowel series (n = 6), CT scan (n = 3), and surgical exploration (n = 2). All patients discharged with improved condition.
Typical US findings of the transient small bowel intussusception included 1) small size without wall swelling, 2) short segment, 3) preserved wall motion, and 4) absence of the lead point. Conservative management with US monitoring rather than an immediate operation is recommended for those patient with typical transient small bowel intussusceptions. Atypical US findings or clinical deterioration of the patient with persistent intussusception warrant surgical exploration.
Children, gastrointestinal tract; Intussusception; Intestine, US
Intussusception is a rare condition in the adult population. However, in contrast to its presentation in children, an identifiable etiology is found in the majority of cases. Clinical manifestations of adult intussusception are non-specific and patients may present with acute, intermittent or chronic symptoms, predominantly those of intestinal obstruction. A 27-year-old male patient with recurrent abdominal pain secondary to intussusception is herein reported. The clinical presentation and ultrasonographic findings led to the diagnosis. At laparotomy, an ileal hamartoma was found as the lead point of the intussusception. Surgical management and histopathologic studies are described. A recurrent intestinal obstruction and classic ultrasound findings may lead to the diagnosis of intussusception but surgical exploration remains essential. The principle of resection without reduction is well established.
Adult intussusception; Ileum hamartoma; Intestinal obstruction
Idiopathic intussusception is an important abdominal emergency in infancy and childhood. Non operative management for treatment is firstly considered due to less invasiveness, less complications and cost effectiveness compared to surgical treatment. This study summarizes our experience in the management of intussusception in children who were referred to a children hospital.
Patients and Methods
A total of 102 children who were diagnosed as having intussusception were referred to one children hospital in Tehran during a period of 10 years, from 1997 to 2007. Reductions were performed upon 57 cases by a radiologist or radiology residents, if there was no medical contraindication. We used chi-square test for analysis.
The success rate of reduction was eight out of 13 (61.5%) with barium, nine out of 17 (53.5%) with air and 22 out of 27 (81.5%) with saline (p value=0.116). One patient had recurrence with air reduction. Another case was complicated by peritonitis using barium enema.
There was no significant relationship between the success rate of reduction and the type of reduction.
Children; Intussusception; Invagination
AIM: To optimize the preoperative diagnosis and surgical management of adult intussusception (AI).
METHODS: A retrospective review of the clinical features, diagnosis, management and pathology 41 adult patients with postoperative diagnoses of intussusception was conducted.
RESULTS: Forty-one patients with 44 intussusceptions were operated on, 24.4% had acute symptoms, 24.4% had subacute symptoms, and 51.2% had chronic symptoms. 70.7% of the patients presented with intestinal obstruction. There were 20 enteric, 15 ileocolic, eight colocolonic and one sigmoidorectal intussusceptions. 65.9% of intussusceptions were diagnosed preoperatively using a computed tomography (CT) scan (90.5% accurate) and ultrasonography (60.0% accurate, rising to 91.7% for patients who had a palpable abdominal mass). Coloscopy located the occupying lesions of the lead point of ileocolic, colocolonic and sigmoidorectal intussusceptions. Four intussusceptions in three patients were simply reduced. Twenty-one patients underwent resection after primary reduction. There was no mortality and anastomosis leakage perioperatively. Except for one patient with multiple small bowel adenomas, which recurred 5 mo after surgery, no patients were recurrent within 6 mo. Pathologically, 54.5% of the intussusceptions had a tumor, of which 27.3% were malignant. 9.1% comprised nontumorous polyps. Four intussusceptions had a gastrojejunostomy with intestinal intubation, and four intussusceptions had no organic lesion.
CONCLUSION: CT is the most effective and accurate diagnostic technique. Colonoscopy can detect most lead point lesions of non-enteric intussusceptions. Intestinal intubation should be avoided.
Adult intussusception; Diagnosis; Management; Computed tomography scan; Intestinal intubation
Intussuception is a rare cause of intestinal obstruction in adults. Diagnosis is often difficult due to the variable and sometimes episodic nature of symptoms. Surgery is the recommended treatment option in adults if the diagnosis is proven.
We present a case of a 33 year old Caucasian female admitted with a small bowel obstruction and no history of previous abdominal surgery. Patient did not improve with medical management consisting of bowel rest and nasogastric tube decompression. Surgery was consulted and patient was taken to the operating room for a laparoscopic-assisted small bowel resection for a small bowel intussusception caused by a submucosal fibroma.
Our case highlights the feasibility and potential benefits of laparoscopy in assisting the diagnosis and treatment of small bowel obstructions.
Adult intussusception is a rare but challenging condition. Preoperative diagnosis is frequently missed or delayed because of nonspecific or sub-acute symptoms.
We present the case of a sixty-two year old gentleman who initially presented with pseudo-obstruction. Computerised tomography displayed a jejuno-jejunal intussusception, which was treated by primary laparoscopic reduction. The patient re-presented with acute small bowel obstruction two weeks later. He underwent a laparotomy showing recurrent intussusception and required a small bowel resection with primary anastomosis. Histological examination of the specimen revealed that the intussusception lead point was due to an inflammatory fibroid polyp (Vanek’s tumour) causing double invagination.
Adult intussusception presents with a variety of acute, intermittent, and chronic symptoms, thus making its preoperative diagnosis difficult. Although computed tomography is useful in confirming an anatomical abnormality, final diagnosis requires histopathological analysis. Vanek’s tumours arising within the small bowel rarely present with obstruction or intussusception. The optimal surgical management of adult small bowel intussusception varies between reduction and resection. Reduction can be attempted in small bowel intussusceptions provided that the segment involved is viable and malignancy is not suspected.
The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/7292185123639943
Vanek’s tumour; Intussusception
OBJECTIVE--To assess the incidence of potentially avoidable factors contributing to death of children with intussusception. DESIGN--Review of children who died with intussusception in England and Wales between 1984 and 1989 from data of the Office of Population Censuses and Surveys, case notes, coroners' records, and necropsy reports. MAIN OUTCOME MEASURES--Unambiguous objective criteria such as failure to diagnose intussusception within 24 hours of admission. RESULTS--33 children died of acute intussusception in England and Wales between 1984 and 1989 compared with 67 in the previous six years. Their median age was 7 months (range 2 months to 12 years), and two thirds were boys. Half of the deaths occurred at home or soon after arrival at hospital but 15 patients had surgery. Potentially avoidable factors contributing to death were identified in 20 (61%) children, all but three of whom had ileocolic intussusception. These factors were excessive delay in diagnosis, inadequate intravenous fluid and antibiotic therapy, delay in recognising recurrent or residual intussusception after hydrostatic reduction, and surgical complications. Of the 13 patients in whom no avoidable factors were identified, there were nine of 11 children with isolated small bowel intussusception, who tended to have atypical presentations. CONCLUSION--Although the mortality from intussusception has declined, there remains ample opportunity for improved management.
Intussusception in adults is uncommon, and it is rare in the descending colon because of its fixation to the retroperitoneum. We herein describe a case of intussusception caused by descending colon cancer. A 74-year-old man was admitted to our hospital for treatment of vomiting and abdominal pain. He had undergone chemotherapy for lymph node recurrence of stomach cancer for about 4 years. Computed tomography revealed a ‘target mass’ with a tumor in the descending colon. We diagnosed his illness as intussusception of a descending colon tumor and performed emergency laparotomy. Conservative resection was performed following anastomosis after reduction of the intussusception. The tumor was pathologically diagnosed as poorly differentiated adenocarcinoma with neuroendocrine features. To the best of our knowledge, this is the first report of an intussusception caused by descending colon cancer incidentally diagnosed during chemotherapy for stomach cancer recurrence.
Intussusception; Descending colon cancer; Stomach cancer recurrence; Chemotherapy
Introduction. Intussusception after bariatric surgery is an uncommon complication that is now being frequently reported. Most people consider dysmotility to be the causative mechanism in the absence of obvious etiology. Material and Methods. A worldwide search identified literature describing intussusception after bariatric surgery. We also included our own patients and analyzed information regarding demographic profile, risk factors, presentation, diagnosis, and post treatment course. Results. Seventy one patients were identified between 1991 and 2011. Majority of the affected patients were females (n = 70, 98.6%); median time to presentation after gastric bypass surgery was 36 months. Most patients presented with abdominal pain, nausea and vomiting, but without obvious peritonitis. Sixty eight patients (96%) required surgery; 48 (70.6%) underwent revision of anastomosis, 16 (23.5%) had reduction without resection, while 4 patients (5.9%) had plication only. Amongst these, most patients (n = 51, 75%) were found to have retrograde intussusception. Post-operatively, 9 patients presented with recurrence (range, 0.5–32 months). Five patients, who had earlier been treated without resection, eventually required revision of the anastomosis. There was no mortality noted. Conclusion. Intussusception after bariatric surgery is uncommon and its diagnosis is based on a combination of physicial, radiological and operative findings. An early surgical intervention reduces morbidity and prevents recurrence.
A case of recurrent acute jejuno-jejunal intussusception presenting in the post operative period of the surgery for acute ileocolic intussusception is presented. Post operative intussusception is defined as intussusception occurring within 30 days of the primary surgery . This is a rare entity. Jejuno-jejunal intussusception is also rare. Recurrent intussusception is uncommon. The present case is a combination of all these rarities.
Recurrent intussusception; Jejuno-jejunal intussusception; Post operative intussusception
Intussusception is a typical abdominal emergency in early childhood.
We report a case of an infant in the typically affected age group with an intussusception triggered by a rare benign intramural intestinal adenomyoma as a pathological lead point. The infant had the typical symptoms of a recurrent idiopathic ileocolic intussusception.
Discussion and evaluation
Idiopathic intussusception is frequent in the infant age group. Contrary to that, reports on pathological lead points for intussusceptions are sparse in the toddler age.
That case illustrates that even in intussusceptions in the typically affected age group, it is important to be aware of pathological lead points, especially if the intussusceptions are recurrent.
Intussusception; Intestinal adenomyoma; Pathological lead point
A case of recurrent acute retrograde jejunogastric intussusception is described in a 45-year-old man who five years previously had had an antecolic gastrojejunostomy.
Two previous haematemases imply that this complication was recurrent and self reducing an unusual and fortuitous outcome.
Awareness of the possibility of acute intussusception following gastroenterostomy or partial gastrectomy is stressed.
Intussusception is recognized as a common cause of bowel obstruction in small animals. This study documents the clinical and surgical findings in nine cats and 27 dogs diagnosed as having intussusception. The main purposes of the study were to define the predisposing causes and clinical signs of intussusception and to evaluate various surgical techniques commonly employed in its treatment. No common predisposing cause could be established. Diagnosis of intussusception was based most often on clinical signs of bowel obstruction in association with the palpable abdominal mass. The majority of the intussusceptions involved the enterocolic junction. Formation of adhesions was more frequent in cats. Surgical treatments included simple reduction, manual reduction with plication, intestinal resection/anastomosis, and intestinal resection/anastamosis with plication. There was no statistically significant difference (p>0.05) in the recurrence rate of the intussusceptions when the various surgical techniques were compared. Recurrence of an intussusception was not related to either the bowel segment involved or whether a simple reduction, bowel resection, or intestinal plication was performed at the initial surgery.
Localized malignant pleural mesothelioma (LMPM) is a rare occurrence, and gastrointestinal intra-luminal metastases have not previously been reported. Herein, we report a patient with LMPM who presented with a local recurrence 10 mo after initial en bloc surgical resection. Abdominal computed tomography was performed for intractable, vague abdominal pain with episodic vomiting, which showed a “target sign” over the left lower quadrant. Laparotomy revealed several intra-luminal metastatic tumors in the small intestine and colon and a segmental resection of metastatic lesions was performed. Unfortunately, the patient died of sepsis despite successful surgical intervention. Though local recurrence is more frequent in LMPM, the possibility of distant metastasis should not be ignored in patients with non-specific abdominal pain.
Localized malignant pleural mesothelioma; Intussusception; Distant metastasis
Background and objective:
With the advent of laparoscopy into pediatric surgical filed and with experience gaining, as well as, improvement in instrumentation, it has been used in management of different conditions, including intussusception. However, there is no universal acceptance regarding its role in reduction of intussusception. This is due to the early reports of high conversion rate and the concern of missing a lead point. The aim of this article is to review the literatures about safety and efficacy of laparoscopy in intussusception management and the limitations as well as formulating a working algorithm for management of intussusceptions in pediatric age group up to 18 years. Up to my knowledge this is the first review article in this subject.
A comprehensive review of the English literature in Pub Med searching engine was conducted with key words laparoscopy, intussusception, management of intussusception, minimal invasive surgery and intussusception, laparoscopic reduction of intussusception, between 1996 and2009 .The results yielded were further explored for citation regarding the role of laparoscopy in reduction of intussusception.
The success rate increased from 57% in 1997 to 91% in 2009 while the conversion rate decreased from 43% in 1997 to 9% in 2009.The presence of a lead point and/or ischemic bowel were the main reasons for conversion in the initial reports.
Laparoscopy is a safe and efficient method for reduction of intussusception. The presence of a lead point or necrotic bowel is no more indication for conversion to open surgery. Laparoscopy should be an integral tool in the management algorithm of intussusception.
intussusception reduction; laparoscopy in children; role of laparoscopy in intussusception
Intussusception (IS) is a common cause of bowel obstruction in the pediatric population. Traditionally, unsuccessful hydrostatic reduction has been followed by laparotomy. With the advent of minimally invasive surgery, centers have adopted laparoscopic reduction as a surgical option. We reviewed our experience with IS and investigated whether there were any advantages to performing laparoscopy over conventional laparotomy in unsuccessful air enema reduction (AE).
All the records of patients admitted from January 2001 to August 2004 with a diagnosis of IS (diagnosis code 560.0) were reviewed. Parameters investigated included age, sex, weight, radiological intervention, operative procedure, length of stay (LOS), and days to oral intake (PO). Statistical analysis was performed with the 2-tailed t test to compare outcomes and Fisher's exact test to assess differences in nominal frequencies.
Seventeen males and 9 females diagnosed with IS were identified. The mean age was 2.5 years (range, 1 month to 14 years), and the average weight was 5.65 kg (range, 4.65 to 95). Twenty-three of the 26 patients (88.5%) underwent AE reduction, with success in 13 (57%). One recurred after initial successful AE, 9 failed multiple attempts at AE, and 2 attempted reductions were complicated by perforations. Fifteen patients underwent surgical reduction for unsuccessful AE or to address a pathological lead point. The success rate of laparoscopic reduction was 85%. The average time to resumption of PO intake for patients with successful AE was 0.5 days, and after laparoscopic reduction, the average time to PO intake was 1.5 days, while it was 4 days after laparotomy (P=0.05). After laparoscopic reduction, the average LOS was 6 days, but LOS was 7 days after laparotomy (P=0.66)
Many children who present with IS can be treated by AE. In patients who fail AE, laparoscopy offers a safe, effective alternative to laparotomy.
Laparoscopy; Laparotomy; Intussusception; Air enema reduction
Adult intussusception is uncommon and requires a surgical approach. Malignancy is associated with 31% (43/137) of small bowel intussusception and 70% (74/106) of large bowel intussusception. Computerized tomography (CT) findings are pathognomonic for this condition. Often, the patient presents with long-standing, nonspecific complaints. A 63-year-old man presented with sudden onset of abdominal pain. CT demonstrated colonic inflammation. A laparoscopic right hemicolectomy for ileocecal intussusception was performed. The pathology report revealed a lipoma of the cecum. The postoperative course was uneventful, and he was discharged the fifth postoperative day. Despite a high incidence of malignancy, colonic or ileocecal intussusception can be successfully treated by laparoscopic resection. Review of the literature and treatment options are discussed.
Laparoscopic hemicolectomy; Ileocecal; Adult intussusception
We have described a previously unreported entity of an intussuscepted neuroendocrine carcinoma of the appendix. Our patient was a 70-year-old man whose only complaint was insipient weight loss. Colonoscopy showed a malignant cecal “polyp”, and an extended right hemicolectomy was performed. We have reviewed the literature on the causes of appendiceal intussusception and their appropriate treatment options, and clarified the classification of neuroendocrine tumors of the gastrointestinal tract.
Neuroendocrine carcinoma; Appendix; Intussusception
Blue rubber bleb naevus syndrome (BRBNS), is an uncommon condition characterised by cavernous haemangiomas of skin and gastrointestinal tract. The most common complication of this syndrome is gastrointestinal bleeding. Intussusception of bowel, although a known complication, has rarely been reported.
We report the case of a 37-year-old man who presented with multiple intussusceptions of small bowel. He required an urgent laparotomy and bowel resections. He suffered from BRBNS. This is the first reported case of multiple synchronous intussusceptions affecting both jejunum and ileum, secondary to haemangiomas occurring in an adult with BRBNS. The underlying conditions of acute abdomen in patients with BRBNS may include intramural haemorrhage, infarction, volvulus or intussusception of bowel. Treatment options include pharmacological manipulation, bowel resection, and interventions such as sclerotherapy, angiographic embolisation, endoscopic ligation, electrocautery and laser photocoagulation for visceral lesions.
A high index of suspicion is required whilst dealing with acute abdomen in patients with BRBNS. Clinical trials may provide some answers as to the preference of treatment in individual cases, as the current level of evidence does not offer a clear choice of optimal treatment.
Mantle cell lymphoma (MCL) is an aggressive type of B-cell non-Hodgkin's lymphoma that originates from small to medium sized lymphocytes located in the mantle zone of the lymph node. Extra nodal involvement is present in the majority of cases, with a peculiar tendency to invade the gastro-intestinal tract in the form of multiple lymphomatous polyposis. MCL can be accurately diagnosed with the use of the highly specific marker Cyclin D1. Few cases of mantle cell lymphoma presenting with intussuception have been reported. Here we present a rare case of multiple intussusceptions caused by mantle cell lymphoma and review the literature of this disease.
A 68-year-old male presented with pain, tenderness in the right lower abdomen, associated with nausea and non-bilious vomiting. CT scan of abdomen revealed ileo-colic intussusception. Laparoscopy confirmed multiple intussusceptions involving ileo-colic and ileo-ileal segments of gastrointestinal tract. A laparoscopically assisted right hemicolectomy and extended ileal resection was performed. Postoperative recovery was uneventful. The histology and immuno-histochemistry of the excised small and large bowel revealed mantle cell lymphoma with multiple lymphomatous polyposis and positivity to Cyclin D1 marker. The patient was successfully treated with Rituximab-CHOP chemotherapy and remains in complete remission at one-year follow-up.
This is a rare case of intestinal lymphomatous polyposis due to mantle cell lymphoma presenting with multiple small bowel intussusceptions. Our case highlights laparoscopic-assisted bowel resection as a potential and feasible option in the multi-disciplinary treatment of mantle cell lymphoma.
Colocolonic intussusception is an uncommon cause of intestinal obstruction in children. The most common type is idiopathic ileocolic intussusception. However, pathologic lead points occur approximately in 5% of cases. In pediatric patients, Meckel’s diverticulum is the most common lead point, followed by polyps and duplication. We present a case of recurrent colocolonic intussusception which caused colonic obstruction in a 10-year-old boy. A barium enema revealed a large polypoid mass at the transverse colon. Colonoscopy showed a colonic polyp, 3.5 centimeters in diameter, which was successfully removed by endoscopic polypectomy.
Colocolonic intussusception; Juvenile polyp; Endoscopic treatment; Large colonic polyp
The “Chinese Fan Spread” (CFS) distraction technique for laparoscopic reduction of intussusception is herein described and its outcome and benefits are evaluated.
A retrospective review was performed of all patients who underwent attempts at laparoscopic reduction of intussusception at our center. The CFS distraction technique was consistently applied in all cases.
Fourteen patients were identified. Median age was 2.4 years (range, 4 months to 10.3 years). Indications for surgery included (1) failed pneumatic reduction (n=11), (2) need to evaluate for lead point in a patient with 4 recurrences (n=1), (3) need to biopsy the lead point in a patient with suspected lymphoma (n=1), and (4) diagnostic laparoscopy for evaluation of hematochezia (n=1). Two patients who failed laparoscopic reduction by the CFS distraction technique also failed open manual reduction, requiring right hemicolectomy. Of the 12 (86%) who were successfully reduced laparoscopically, pathologic lead points were identified in 5 (2 acute appendicitis, 1 Meckel's diverticulum, 1 harmatomatous polyp, and 1 Burkitt's lymphoma). Lead points were excised laparoscopically or via a vertical transumbilical incision. There were no complications.
Laparoscopic reduction of intussusception by the CFS distraction technique is effective and safe. Lead points may be dealt with together either laparoscopically or via a transumbilical incision.
Laparoscopic reduction of intussusception; Children; Chinese fan spread