Surg Today (2009) 39:861–865DOI 10.1007/s00595-009-3979-8

Reprint requests to: A. Demirkan, AUTF Ibni Sina Hastanesi Acil Anabilim Dalı, 06100 Sıhhiye, Ankara, TurkeyReceived: July 6, 2008 / Accepted: March 5, 2009

Intussusception in Adult and Pediatric Patients: Two Different Entities

ARDA DEMIRKAN1, AYDIN YAGMURLU

2, I.LKNUR KEPENEKCI

1, MARLEN SULAIMANOV1, ETHEM GECIM

1,

and HÜSEYIN DINDAR2

Departments of 1 General Surgery and 2 Pediatric Surgery, School of Medicine, Ankara University, Ankara, Turkey

AbstractPurpose. Intussusception is one of the most common abdominal emergencies in pediatrics, but adult intus-susception is an uncommon entity and most surgeons have only limited experience in treating this disease. The purpose of this study was to highlight the differ-ences between pediatric and adult intussusception.Methods. The records of 40 patients during 14 years were reviewed retrospectively. The symptoms, diagno-sis, sites of intussusception, associated pathologies, and treatment methods of each patient were analyzed.Results. A total of 31 pediatric and 9 adult patients were included in the study. In the pediatric group, bloody stool and vomiting were the most common symptoms whereas adult patients commonly presented with abdominal pain. The physical examination was diagnos-tic in a remarkable proportion of the pediatric patients but the diagnosis was suggested based on imaging tech-niques in the adults, and preoperative diagnosis was more successful in the pediatric group. Intussusception was more often associated with an underlying pathology in adults and no adult patient underwent nonoperative reduction, whereas pediatric patients were managed either with hydrostatic reduction or surgery.Conclusions. Although intussusceptions occur at all ages, there are major differences in the clinical presen-tation, diagnostic approach, and management between pediatric and adult populations. Intussusception is remarkably different in these two age groups and it must be approached from a different clinical perspective.

Key words Intussusception · Adult · Pediatric

Introduction

Intussusception is one of the most common causes of intestinal obstruction in the pediatric population;1,2 con-versely, adult intussusception is a relatively rare condi-tion which accounts for only 1%–3% of the patients with intestinal obstruction and 5%–10% of all intus-susceptions.3–7 Pediatric patients with intussusception tend to show an acute presentation, while the symptoms of adult patients are usually nonspecifi c, less obvious, and sometimes chronic with recurrent episodes of sub-acute obstruction.8–13 Therefore, the diagnosis in adults is often more diffi cult and this may cause a delay in the treatment.

In pediatric ages there is rarely any associated patho-logic process that provides a lead point for intussuscep-tion.1,2 The possible causes include Meckel’s diverticulum, hypertrophy of Peyer’s patches in the terminal ileum as a result of an antecedent viral infection appendicitis, and rotavirus vaccination.14–17 In contrast to pediatrics, a pre-disposing organic cause is present in the majority of cases in adults.6,10,18,19 This renders the situation even more complicated. Either primary or metastatic tumors and polyps are commonly the lead point of intussuscep-tion, while infl ammation or adhesions from previous surgery can also cause intestinal intussusception.12,13 Intussusception in adults and children also tends to dem-onstrate different pathologies. In addition, many sur-geons have limited experience with such clinical entities and with the various considerations involved in diagno-sis and management.18,19 We herein report our experi-ence in an attempt to highlight the differences between adult and pediatric patients with intussusception.

Patients and Methods

We reviewed the records of general surgery and pedi-atric surgery departments from 1991 to 2005. A total of

862 A. Demirkan et al.: Pediatric and Adult Intussusception

40 patients who had a diagnosis of intussusceptions were identifi ed. The patients were then separated into pediatric (age 0–16) and adult (age over 16) groups. Any patients with stomal intussusceptions and jejuno-gastric intussusceptions after gastroenterostomies were excluded from the study. The data from these 40 patients were obtained from the patient charts, operative notes, and pathology reports.

The symptoms at the time of admission were clas-sifi ed as abdominal pain, irritability, bloody stools, jaundice, diarrhea, vomiting, obstipation, and rectal prolapsus in both adult and pediatric groups. Imaging modalities that were performed to aid diagnosis included ultrasonography, computed tomography, and barium study. Not all of these tests were performed for every patient and the test that confi rmed the diagnosis of intussusception for each patient was recorded. The patients were managed either surgically or nonsurgi-cally by hydrostatic reduction. The site of intussuscep-tion, the underlying pathology, and the type of operation performed were reviewed from the operation notes of the patients. Finally, the success of the preoperative diagnosis of intussusception was analyzed.

The differences between the selected categorical vari-ables were analyzed with Fisher’s Exact Test. SPSS for Windows 11.5 (Chicago, IL, USA) was used for a sta-tistical evaluation. A P value of less than 0.05 was con-sidered to be signifi cant. The data are presented as the mean ± SD.

Results

Forty cases of intussusception have been diagnosed in general surgery and pediatric surgery clinics during the past 14 years. The pediatric group consisted of 31 (7 female and 24 male) patients, while the adult group consisted of 9 (4 female 5 male) patients. The age of the adult patients ranged between 28 and 70, with a mean age of 43.7 ± 18 years. In the pediatric group the age of the patients ranged between 6 months and 3 years with a mean age of mean 0.7 ± 0.8 years.

The most common complaint in adult patients was abdominal pain; it was present in 7 of 9 patients at the time of admission. Abdominal pain was also observed in pediatric patients but it was not as common as that seen in adults (77.8% vs 19.4%, P = 0.002). Bloody stool was the chief complaint among pediatrics. It was present in 25 of 31 pediatric patients while only one of the adult patients had this complaint (80.6% vs 11.1%, P < 0.001). Jaundice (55.6% vs 0%, P < 0.001) and obstipation (22.2% vs 0% P = 0.046) were present only in adult patients. Vomiting was observed in 24 (77.4%) patients of the pediatric group and 4 (44.7%) patients of the adult group but the difference was nonsignifi cant. Other

symptoms including irritability, diarrhea, and rectal prolapsus in pediatrics were not observed in the adult patients (Table 1).

The diagnosis of intussusception was based on a phys-ical examination in 14 patients of the pediatric group; however, none of the adults was diagnosed based on a physical examination (45.2% vs 0%, P = 0.016). In the remaining pediatric patients, the diagnosis was estab-lished by either an ultrasound or barium study. Ultra-sound had been reported to be the most frequently performed imaging technique in diagnosing intussus-ception in both the adult and pediatric groups. In both pediatric and adult patients who were diagnosed by ultrasonography, intussuscepted bowel loops were observed as either a “target lesion” or “pseudokidney sign.” Computed tomography revealed the diagnosis of intussusception in two adult patients but it was not per-formed in pediatrics (P = 0.046). Computed tomogra-phy scans demonstrated a target appearance in one patient and a sausage-shaped mass accompanied by a small bowel dilatation and air-fl uid levels representing small bowel obstruction in the other patient. The leading point of intussusception was therefore apparent in both of these patients. Intussusception was diagnosed by preoperative examinations in 27 of 31 (87.1%) pediatric and 4 of 9 (44.4%) adult patients (P = 0.016) (Table 2).

The terminal ileum was the site of intussusception in most of the adult patients (55.5%), but we did not observe any intussusception at this location in the pedi-atric group (0%) (P = 0.001). Ileocolic intussusception was the most common type in pediatric patients, being observed in 41.9% of the cases, and it was also observed in 22% of the adult cases (P = not signifi cant). Ileoileal intussusception had the same frequency (22%) in the adult and pediatric groups (Table 3).

All of the adult patients were treated surgically with midline incisions. Either an intestinal resection with anastomosis (77.7%) or an enterotomy for mass exci-sion (22.2%) was performed. In two adult patients, the

Table 1. Symptoms and signs of adult and pediatric patients with intussusception

Adult Pediatric

P valuen % n %

Abdominal pain 7 77.8 6 19.4 0.002Irritability 0 0 3 9.7 n.s.Bloody stools 1 11.1 25 80.6 <0.001Jaundice 5 55.6 0 0 <0.001Diarrhea 0 0 2 6.5 n.sVomiting 4 44.7 24 77.4 n.s.Obstipation 2 22.2 0 0 0.046Rectal prolapse 0 0 1 3.2 n.s.

n.s., not signifi cant

A. Demirkan et al.: Pediatric and Adult Intussusception 863

causative pathology was an ileal polyp (22.2%) and an enterotomy for a mass excision was a suffi cient treat-ment. An intestinal resection with anastomosis was performed in seven adult patients. This procedure was performed due to the tumoral masses in four of these patients, while it was performed because of intestinal necrosis in three of them. The histopathological exami-nations of the tumoral masses confi rmed adenocarci-noma in all four patients.

Eleven patients in the pediatric group were treated with hydrostatic reduction and 15 were treated with laparotomy-manual reduction. A resection of the involved segment was required in fi ve pediatric patients. In three pediatric patients Meckel’s diverticulum was the lead point of the intussusception (Table 4). In addi-tion, 28 of 31 pediatric intussusceptions and 3 of 9 adult intussusceptions were considered to be either idiopathic in nature or due to gastroenteritis, and a statistically

signifi cant difference was observed between the two groups (90.3% vs 33.3%, P = 0.001) (Table 5). All adult and pediatric patients have been discharged without any complications.

Discussion

Intussusception is one of the most common abdominal emergency situations in infants and small children, and the classic clinical presentation is usually diagnostic.1,2 On the other hand it is rare in adults and nonspecifi c; variable signs and symptoms can therefore be a chal-lenge to diagnose. Imaging techniques are used exten-sively to aid in the diagnosis in adults and most cases are recognized in the patients that undergo imaging for nonspecifi c abdominal pain or suspected bowel obstruction.10,11,19,20 In our experience, bloody stool and

Table 2. Diagnostic techniques which were useful for the diagnosis of intussusception in the adult and pediatric groups

Adult Pediatric

P valuen % n %

History 0 0 4 12.9 n.s.Physical examination 0 0 14 45.2 0.016Ultrasonography 4 44.4 10 32.3 n.s.Barium study 0 0 6 19.4 n.s.Computed tomography 2 22.2 0 0 0.046Preoperative correct diagnosis 4 44.4 27 87.1 0.016

Table 3. Site of intussusceptions in adult and pediatric patients

Adult Pediatric

P valuen % n %

Ileoileal 2 22.2 2 6.5 n.s.Terminal ileum 5 55.6 0 0 0.001Cecal 0 0 1 3.2 n.s.Ileocecal 0 0 7 22.6 n.s.Ileocolic 2 22.2 13 41.9 n.s.Ileocecocolic 0 0 6 19.4 n.s.Colocolonic 0 0 2 6.5 n.s.

Total 9 100 31 100

Table 4. Management of adult and pediatric patients with intussusception

Adult Pediatric

P valuen % n %

Hydrostatic reduction 0 0 11 35.4 0.043Laparotomy and manual reduction 0 0 15 48.3 0.015Enterotomy and mass excision 2 22.2 0 0 0.046Intestinal resection with anastomosis 7 77.7 5 16.1 0.001

Total 9 100 31 100

864 A. Demirkan et al.: Pediatric and Adult Intussusception

vomiting were the most common symptoms in the pedi-atric group. A physical examination alone was diagnos-tic in a remarkable portion of these patients, and ultrasound and barium studies resulted in a diagnosis in the remaining ones. The clinical presentation was more complicated in adults. Although abdominal pain was the most common presentation, it was accompanied by varying symptoms. In experienced hands ultrasound has both a high sensitivity and specifi city in the detection of intussusception. Ultrasound has been shown to be the fi rst-choice imaging technique in diagnosing intussus-ception owing to its advantage of being easy to perform, reproducible, fast, and cheap.21–23 In our series, ultra-sound was the most helpful technique for making a diagnosis in both adults and pediatrics. Computed tomography is normally not indicated in pediatrics; however, it is very helpful for the evaluation of possible intussusception in adults.11,19,24,25 In these patients, com-puted tomography aids in both making an accurate diagnosis and also for identifying any associated under-lying causes.

Despite the wide use of these imaging techniques, the diagnosis of intussusception in adults remains diffi cult and it therefore is often confi rmed only after a laparot-omy.10,19 In our series, the rate of a preoperative correct diagnosis was signifi cantly higher in the pediatric group than in the adult group.

Management of pediatric and adult patients is also quite different. In pediatric patients there is usually no specifi c underlying cause so they can be managed suc-cessfully with nonsurgical techniques.21,26,27 Hydrostatic pressure reduction makes surgery unnecessary in a high percentage of pediatric patients with intussusception. In patients in whom nonsurgical attempts fail, a laparot-omy with manual reduction is suffi cient in noncompli-cated cases. In contrast to pediatric patients most of the adult patients have an associated pathologic process and unlike pediatric patients, intussusception remains a surgical disease in adults. Intussusception has been con-sidered to be an indication for surgical treatment in adults as a result of the risk of ischemia and the possibil-ity of a malignant lead point.6,10,13,19,28 There were no patients in the adult group of our series with radio-

graphically documented intussusception who under-went nonsurgical reduction. An intestinal resection with anastomosis was performed in four patients with malig-nant tumors, while an enterotomy for a mass excision was performed in two patients with polyps.

The fi ndings of this study suggest that, although intussusception occurs at all ages, there are major dif-ferences in the clinical presentation, diagnostic approach, and management of intussusception between the pedi-atric and adult populations. As a result, even though the disease is the same, the disease process is remark-ably different in these two age groups and it there-fore must be approached from a different clinical perspective.

References

1. Ein SH, Stephens CA. Intussusception: 354 cases in 10 years. J Pediatr Surg 1971;6:16–27.

2. Bisset GS 3rd, Kirks DR. Intussusception in infants and children: diagnosis and therapy. Radiology 1988;168:141–5.

3. Laws HL, Aldrete JS. Small-bowel obstruction: a review of 465 cases. South Med J 1976;69:733–4.

4. Stewardson RH, Bombeck CT, Nyhus LM. Critical operative management of small bowel obstruction. Ann Surg 1978;187:189–93.

5. Briggs DF, Carpathios J, Zollinger RW. Intussusception in adults. Am J Surg 1961;101:109–13.

6. Agha FP. Intussusception in adults. Am J Roentgenol 1986;146:527–31.

7. Felix EL, Cohen MH, Bernstein AD, Schwartz JH. Adult intus-susception: case report of recurrent intussusception and review of the literature. Am J Surg 1976;131:758–61.

8. Reijnen HA, Jooslen HJ, De Boer HH. Diagnosis and treatment of adult intussusception. Am J Surg 1989;158:25–8.

9. Takeuchi K, Tsuzuki Y, Ando T, Sekihara M, Hara T, Kori T, et al. The diagnosis and treatment of adult intussusception. J Clin Gastroenterol 2003;36:18–21.

10. Nagorney DM, Sarr MG, McIlrath DC. Surgical management of intussusception in the adult. Ann Surg 1981;193:230–6.

11. Yalamarthi S, Smith RC. Adult intussusception: case reports and review of literature. Postgrad Med J 2005;81:174–7.

12. Shibata Y, Sato K, Kodama M, Nanjyo H. Metastatic liposarcoma in the jejunum causing intussusception: report of a case. Surg Today 2008;38(12):1129–32.

13. Shinoda M, Hatano S, Kawakubo H, Kakefuda T, Omori T, Ishii S. Adult cecoanal intussusception caused by cecum cancer: report of a case. Surg Today 2007;37(9):802–5.

Table 5. Etiology of intussusceptions in adult and pediatric patients

Adult Pediatric

P valuen % n %

Ileal polyp 2 22.2 0 0 0.46Ileal tumor 2 22.2 0 0 0.46Ileocecal tumor 2 22.2 0 0 0.46Meckel’s diverticulum 0 0 3 9.7 n.s.Gastroenteritis—idiopathic 3 33.3 28 90.3 0.001

Total 9 100 31 100

A. Demirkan et al.: Pediatric and Adult Intussusception 865

14. Navarro OM, Daneman A, Cha A. Intussusception: the use of delayed, repeated reduction attempts and the management of intussusceptions due to pathologic lead points in pediatric patients. Am J Roentgenol 2004;182:1169–76.

15. Robinson CG, Hernanz-Schulman M, Zhu Y, Griffi n MR, Gruber W, Edwards KM. Evaluation of anatomic changes in young children with natural rotavirus infection: is intussusception biologically plausible? J Infect Dis 2004;189:1382–7.

16. Bines JE. Rotavirus vaccines and intussusception risk. Curr Opin Gastroenterol 2005;21:20–5.

17. Hsu HY, Kao CL, Huang LM, Ni YH, Lai HS, Lin FY, et al. Viral etiology of intussusception in Taiwanese childhood. Pediatr Infect Dis J 1998;17:893–8.

18. Begos DG, Sandor A, Modlin IM. The diagnosis and manage-ment of adult intussusception. Am J Surg 1997;173:88–94.

19. Azar T, Berger DL. Adult intussusception. Ann Surg 1997;226:134–8.

20. Goh BK, Yeo AW, Koong HN, Ooi LL, Wong WK. Laparotomy for acute complications of gastrointestinal metastases from lung cancer: is it a worthwhile or futile effort? Surg Today 2007;37:370–4.

21. Woo SK, Kim JS, Suh SJ, Paik TW, Choi SO. Childhood intus-susception: US-guided hydrostatic reduction. Radiology 1992;182:77–80.

22. Weissberg DL, Scheible W, Leopold GA. Ultrasonographic appearance of adult intussusception. Radiology 1977;124:791–2.

23. Kojima Y, Tsuchiyama T, Niimoto 5, Nakagawara G. Adult intus-susception caused by cecal cancer and diagnosed preoperatively by ultrasonography. J Clin Ultrasound 1992;20:360–3.

24. Gayer G, Zissin R, Apter S, Papa M, Hertz M. Adult intussuscep-tion- a CT diagnosis. Br J Radiol 2002;75:185–90.

25. Merine D, Fishman EK, Jones B, Siegelman SS. Enteroenteric intussusception: CT fi ndings in nine patients. Am J Roentgenol 1987;148:1129–32.

26. Hays DM, Gwinn JL. The changing face of intussusception. JAMA 1966;195:817–20.

27. del-Pozo G, Albillos JC, Tejedor D, Calero R, Rasero M, de-la-Calle U, et al. Intussusception in children: current concepts in diagnosis and enema reduction. Radiographics 1999;19:299–319.

28. Brayton D, Norris WJ. Intussusception in adults. Am J Surg 1954;88:32–42.

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