CASE REPORT

Colonic Intussusception Induced by Massive TubularAdenoma in a Patient Post-Radiofrequency Ablation

Alex Baronowsky & Seth Lipka & Rinal Patel &Jorge Hurtado-Cordovi & Lester Freedman &

Toshimasa Clark & Prakash Viswanathan &

Kaleem Rizvon & Paul Mustacchia

# Springer Science+Business Media New York 2013

Introduction

While intussusception is commonly reported in children, itis quite rare in adults and almost always secondary to adefinable lesion. Incidence of adult intussusception has beenestimated to range from 0.003 to 0.02 % [1]. We present acase of a 63-year-old male who presented to the emergencyroom with severe abdominal pain and later was found tohave an ascending colonic intussusception.

Case Presentation

A 63-year-old Korean male presented to the emergencyroom with a chief complaint of acute severe right-sidedabdominal pain. His past medical history included ahepatocellular carcinoma for which he receivedradiofrequency ablation 1 year prior, alcoholic livercirrhosis, and hypertension. He described the pain asconstant, sharp, non-radiating, 10/10 in intensity, locatedin the right side of the abdomen, and “a feeling as ifsomething is twisting inside my abdomen.” Family andsocial history was remarkable for chronic alcoholism forwhich he quit 1 year prior.

Vital signs revealed BP=106/42 mmHg, P=110 bpm,RR=20 cpm, and temperature=98.8 °F. Physical examwas remarkable for abdominal tenderness on the rightside, and bowel sounds were hyperactive, with a 3-cmhardened mass located in the right lower quadrant.Rectal exam showed no frank blood. Cardiovascularand respiratory examinations were within normal limits.No edema was noted in the extremities. Initial labora-tory studies showed a hemoglobin/hematocrit ratio of10/29 [(13.5–16.5 g/dL)/(41–50 %)], white blood cellcount 3.8 (4,500–11,000/mm3), and platelets 64,000.The liver-related tests revealed an AST of 32 (0–35 U/L), ALT of 19 (0–35 U/L), total bilirubin 0.7(0.3–1.2 mg/dL), alkaline phosphatase 122 (36–92 U/L), and albumin 3.2 (3.5–5.5 g/dL). A stat CTscan of the abdomen with oral and IV contrast revealeda mid-ascending colonic mass measuring 7.1×6.6 cmwith an associated intussusception, and unchanged cir-rhotic liver with a right lobe mass grossly unchangedfrom a previous study (Figs. 1, 2, and 3). The patient

A. Baronowsky : S. Lipka (*) :R. Patel : J. Hurtado-CordoviDepartment of Medicine, Nassau University Medical CenterAssociated with North Shore-Long Island Jewish Health CareSystem, 2201 Hempstead Turnpike,East Meadow, NY 11554, USAe-mail: seth.lipka@gmail.com

L. FreedmanDepartment of Pathology, Nassau University Medical CenterAssociated with North Shore-Long Island Jewish Health CareSystem, 2201 Hempstead Turnpike,East Meadow, NY 11554, USA

T. ClarkDepartment of Radiology, Nassau University Medical CenterAssociated with North Shore-Long Island Jewish Health CareSystem, 2201 Hempstead Turnpike,East Meadow, NY 11554, USA

P. Viswanathan :K. Rizvon : P. MustacchiaDivision of Gastroenterology, Department of Medicine, NassauUniversity Medical Center Associated with North Shore-LongIsland Jewish Health Care System, 2201 Hempstead Turnpike,East Meadow, NY 11554, USA

J Gastrointest CancDOI 10.1007/s12029-013-9494-6

was taken urgently to the operating room where anexploratory laparotomy was performed with a righthemicolectomy and reanastomosis. The lead point forthe intussusception was a 7.1×6.6-cm mass located inthe mid-ascending colon found to be a tubular adenoma(Fig. 4) on pathological exam. The patient was startedon a clear liquid diet on postoperative day 3 anddischarged on a regular diet by day 5 with a completeresolution of symptoms.

Discussion

It is estimated that general surgeons may only see one or twocases of adult intussusception during their career. Adult

intussusception accounts for less than 5 % of all intussus-ceptions across all age groups and less than 1 % of all bowelobstructions in adults [2]. In about 70–90 % of adult cases,there is a leading mass identified. Malignancy accounts forapproximately 50 % of large bowel intussusception inadults; the majority is primary adenocarcinoma, lymphoma,or metastasis with colorectal adenomas accounting for 5 %of adult cases [3, 7].

Clinical diagnosis of intussusception in adults ismuch more difficult than that in children. The clinicalsigns in adults tend to be of a chronic or subacutenature [1]. The classic triad of non-bilious vomiting,blood per rectum, and nausea seen in about 90 % ofpediatric cases is not commonly found in adults. Themost common findings in adult intussusception are ab-dominal pain, nausea, vomiting, and mass on CT of theabdomen [4]. In adults, the initial signs and symptomsmay be consistent with partial bowel obstruction, andoften, the only symptom is vague abdominal pain [5].Most often, abdominal CT scan with oral and IV con-trast is used to diagnose and has been shown to be themost sensitive diagnostic method in adults [1, 6]. Asseen in this case, a targetoid mass in the ascendingcolon is a classic sign seen on CT for a colo-colicintussusception (Fig. 2). Another common radiographicfinding of note in this case is in the coronalreconstructed CT image showing “cupping” (Fig. 3).Ultrasonography is another useful diagnostic technique;however, the accuracy of the test is highly operatordependent and may be less sensitive than that of CT.Plain-film radiographs may be the first step in diagnosisif an obstructed bowel is clinically suspected. Bariumenema may be another useful tool in suspected colo-colic intussusception and may show a “cup-shaped”filling defect or “coiled spring” sign [4].

Treatment of adult intussusception is not universallyagreed upon; however, almost all surgeons agree thatlaparotomy must be performed due to the risk of bowelnecrosis and subsequent rupture. Recently, secondary toCT imaging, an increase in the number of idiopathic andincidental cases is on the rise. The use of CT in thediagnosis of intussusception may help to differentiatebetween pathologic and idiopathic cases, allowing forthe option of more conservative approach in those cases[7]. When a malignancy is the lead point, removal of amass in the surrounding colon with clean margins is thebest therapy. Excessive manipulation of the bowel shouldbe avoided due to the risk of seeding of malignancy intothe surrounding structures [5, 8]. In contrast, intussus-ception in children is rarely of malignant etiology, andoften, reduction of the intussusception using less invasivemethods is sufficient for the treatment.

Fig. 1 Axial contrast-enhanced CT image through the abdomen dem-onstrates circumferential mass-like thickening of the ascending colonmeasuring 7.1×6.6 cm

Fig. 2 A second axial section obtained at a level slightly below that of theprevious figure demonstrates mesenteric fat and a segment of the ascend-ing colon containing oral contrast within the larger, circumferential mass

J Gastrointest Canc

In the case presented here, there is a question if thepatient's history of radiofrequency ablation therapy puthim at risk for the development of the ascending colonintussusception. Radiation therapies have been shown toincrease the risk of malignant neoplasia. It is unknownwhether the radiotherapy contributed to the formation ofthe tubular adenoma seen in this patient that lead to theascending colon intussusception. To the authors' knowledge,no such case has been reported in the literature nor has thisquestion been addressed. A review of case histories of colo-

colic intussusception in adults with an emphasis onascertaining patient radiation exposure may be warranted.

Conflict of interest The authors declare that they have no conflict ofinterest.

References

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2. Choi SH, Han JK, Kim SH, et al. Intussusception in adults: fromstomach to rectum. AJR AM J Roentgenol. 2004;183(3):691–8.

3. Nagorney DM, Sarr MG, McLLrath DC. Surgical management ofintussusception in the adult. Ann Surg. 1981;193(2):230–6.

4. Marinis A, Yiallourou A, Samanides L, et al. Intussusception of thebowel in adults: a review. World J Gastroenterol. 2009;15(4):407–11.

5. Cakir M, Tekin A, Kucukkartallar T, et al. Intussusception: as thecause of mechanical bowel obstruction in adults. Korean JGastroenterol. 2013;61(1):17–21.

6. Takeuchi K, Tsuzuki Y, Ando T, et al. The diagnosis and treatmentof adult intussusception. J Clin Gastroenterol. 2003;36(1):18–21.

7. Onkendi EO, Grotz TE, Murray JA, Donohue JH. Adult intussus-ception in the last 25 years of modern imaging: is surgery stillindicated? J Gastrointest Surg. 2011;15:1699–705.

8. Gayer G, Zissin R, Apter S, et al. Pictorial review: adult intussus-ception—a CT diagnosis. Br J Radiol. 2002;75(890):185–90.

Fig. 3 A coronal maximumintensity projectionreconstructed imagedemonstrates colo-colonicintussusception. Theintussusceptum andintussuscipiens are labeled, andmesenteric fat is seen separatingthe two

Fig. 4 H&E stain of colonic masses revealing tubular adenoma

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