AJR 2004; 183:691-698
© American Roentgen Ray Society
Intussusception in Adults: From Stomach to Rectum
Seung Hong Choi1,
Joon Koo Han1,
Se Hyung Kim1,
Jeong Min Lee1,
Kyoung Ho Lee1,
Young Jun Kim1,
Su Kyung An1 and
Byung Ihn Choi1
1 All authors: Department of Radiology, Seoul National University College of
Medicine, Institute of Radiation Medicine and Clinical Research Institute,
Seoul National University Hospital, 28 Yongon-dong, Chongno-gu, Seoul 110-744,
South Korea.
Received September 3, 2003;
accepted after revision May 17, 2004.
Address correspondence to J. K. Han
(hanjk{at}radcom.snu.ac.kr).
Intussusception in adults is rare. It is estimated to account for only 5%
of all intussusceptions and causes only 1% of all bowel obstructions and
0.003–0.02% of all hospital admissions
[1]. About 90% of
intussusceptions in adults are caused by a definite underlying disorder such
as a neoplasm or by a postoperative condition
[2]. However, neoplasm is the
most common cause and is found in approximately 65% of adult cases
[3]. Malignant tumors are more
common than benign tumors in the colon, although the reverse is true in the
small bowel. In this article, we describe the characteristic radiologic
features of intussusception according to location and cause and correlate
these with the pathologic findings.
Clinical and Imaging Features
The most common symptoms of intussusception are abdominal pain, nausea, and
vomiting; less frequent symptoms are melena, weight loss, fever, and
constipation [4]. Symptoms are
usually of long duration (several weeks to several months), although the
patient may occasionally present with an acute abdomen
[4].
It is generally believed that masses in the bowel or lumen act as an
irritant and provoke abnormal peristaltic movement, which may lead to the
telescoping of one bowel segment over the adjacent segment. Intussusception
appears as a complex soft-tissue mass consisting of the outer intussuscipiens
and the central intussusceptum (Fig.
1). Any tumor acting as the lead point of an intussusception may
be outlined distal to the tapered lumen of the intussusceptum. Barium reflux
in the lumen of the space between the intussusceptum and intussuscipiens
allows the coiled spring to be visualized. Intussusception is well diagnosed
on CT, which shows a pathognomonic bowel-within-bowel configuration with or
without contained fat and mesenteric vessels
[3]. Intussusception appears as
a sausage-shaped mass when the CT beam is parallel to its longitudinal axis
but as a targetlike mass when the beam is perpendicular to the longitudinal
axis [4]. Sonography can make
the diagnosis of an intussusception in an adult when the characteristic sign
of a targetlike lesion or bull's eye lesion is shown, similar to the CT
findings. The central echogenic area is produced by the mucosa of the
intussusception, which is surrounded by a hypoechoic ring representing the
walls of both the intussusceptum and the intussuscipiens
[5].
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Fig. 1. —Schematic drawings of intussusception. Longitudinal and serial
cross-sectional diagrams of intussusception show invagination of one segment
of gastrointestinal tract (intussusceptum) (thick solid arrows) into
adjacent segment (intussuscipiens) (open arrows). Proximal
cross-sectional diagram of intussusception (bottom right) shows two layers,
although classic appearance of three layers (middle bottom) is shown in mid
portion of intussusception. Note invagination of mesentery, mesenteric vessels
(arrowheads), and hyperplastic mesenteric lymph nodes (thin solid
arrows). LP = lead point, M = mesentery.
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Gastric Intussusception
Gastric intussusception is a rarely documented condition that occurs
secondary to a mobile gastric tumor that prolapses into the small bowel.
Various gastric lesions including adenoma, leiomyoma, lipoma, hamartoma,
inflammatory fibrinoid polyp, adenocarcinoma, and leiomyosarcoma can serve as
lead points. Typical radiologic findings include foreshortening and narrowing
of the gastric antrum, converging or telescoping of mucosal folds in the
antrum or duodenum, prepyloric collar-shaped outpouchings, and widening of the
pyloric canal and the duodenum with an associated lead point (Figs.
2A,
2B and
3A,
3B).
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Fig. 2A. —71-year-old woman with gastroduodenal intussusception caused by
prolapsed antral mass of early gastric cancer type I. Contrast-enhanced CT
scan shows homogeneously enhancing mass (arrows), continuous to
antrum, is prolapsed and located on duodenal bulb.
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Fig. 2B. —71-year-old woman with gastroduodenal intussusception caused by
prolapsed antral mass of early gastric cancer type I. Double-contrast barium
study shows large filling defect (arrows) on duodenal bulb that seems
to have stalk (arrowheads) attached to prepyloric antrum of stomach.
Subtotal gastrectomy was performed. Lobulated 5 x 6 cm mass was found in
greater curvature side of antrum. This lesion was confined to submucosa and
was finally diagnosed as early gastric cancer type I.
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Fig. 3A. —48-year-old woman with gastroduodenal intussusception caused by
Brunner's gland hamartoma of pylorus. Double-contrast barium study shows
narrow and tapered barium streaks (single arrow) representing
intussusceptum. Coiled spring appearance (arrowheads) of duodenum is
clearly seen. Lobulated mass (double arrows), identified as lead
point, is also found in duodenojejunal junction. On contrast-enhanced CT scan
(not shown), it is difficult to differentiate lesion from diffuse wall
thickening of duodenum.
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Fig. 3B. —48-year-old woman with gastroduodenal intussusception caused by
Brunner's gland hamartoma of pylorus. Photograph of resected gastrectomy
specimen shows polypoid mass with long stalk and ulceration
(arrowhead) at pylorus (arrow) of stomach. D = duodenum, P =
pylorus, S = stomach.
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Small-Bowel Intussusception
Although surgical intervention is considered necessary in intussusception
in adults when patients are symptomatic, many asymptomatic and likely
transient intussusceptions may be incidentally detected on CT. When
self-limited, they do not require therapy
[6]. Small-bowel
intussusceptions are secondary to benign lesions in most cases, with malignant
lesions causing 15% of cases and idiopathic intussusceptions accounting for
approximately 20% [4]. Benign
causes include neoplasms such as gastrointestinal stromal tumors (GISTs),
nonneoplastic polyps, congenital lesions such as Meckel's diverticulum and
intestinal duplication, inflammatory lesions, and trauma. Malignant lesions
causing intussusception in the small bowel include adenocarcinoma; malignant
GIST; metastasis from various primary sites such as the lung or breast;
malignant melanoma; osteosarcoma and lymphoma; and primary lymphoma (Figs.
4A,
4B,
4C and
5A,
5B,
5C).
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Fig. 4A. —71-year-old woman with jejunojejunal intussusception caused by
metastatic malignant melanoma. Contrast-enhanced CT scans show collection of
alternating low- and high-attenuation layers surrounded by thin rim of
intussuscipiens (solid straight arrows). Bowel walls of
intussusceptum (arrowheads) are thickened and well enhanced. Central
necrotic mass (open arrow, B) serves as lead point and is
located at tip of intussusceptum. Note another small necrotic nodule
(curved arrow, A) in proximal portion of intussusception.
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Fig. 4B. —71-year-old woman with jejunojejunal intussusception caused by
metastatic malignant melanoma. Contrast-enhanced CT scans show collection of
alternating low- and high-attenuation layers surrounded by thin rim of
intussuscipiens (solid straight arrows). Bowel walls of
intussusceptum (arrowheads) are thickened and well enhanced. Central
necrotic mass (open arrow, B) serves as lead point and is
located at tip of intussusceptum. Note another small necrotic nodule
(curved arrow, A) in proximal portion of intussusception.
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Fig. 4C. —71-year-old woman with jejunojejunal intussusception caused by
metastatic malignant melanoma. Radiograph obtained during small-bowel
follow-through shows intraluminal masses (arrows) at duodenum and
proximal jejunum. One of these (mass in radiopaque circle) shows irregular
barium collection in central ulceration resulting in bull's eye appearance and
surrounding coiled spring appearance (arrowheads).
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Fig. 5A. —39-year-old woman with jejunojejunal intussusception caused by
metastatic osteosarcoma. Patient had history of limb salvage operation due to
osteosarcoma of left femur and presented with abdominal pain of sudden onset.
Small-bowel resection and anastomosis were performed. Pathologic finding
revealed metastatic osteosarcoma in small bowel (not shown). CT scan shows
sausage-shaped mass with well-enhanced portion (arrows), representing
bowel wall of intussuscipiens within intussusceptum at its periphery and
central fatty density, representing mesenteric fat. Linear enhancing
structures within mesenteric fat are mesenteric blood vessels
(arrowheads). This appearance occurs when intussusception is parallel
with CT beam.
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Fig. 5B. —39-year-old woman with jejunojejunal intussusception caused by
metastatic osteosarcoma. Patient had history of limb salvage operation due to
osteosarcoma of left femur and presented with abdominal pain of sudden onset.
Small-bowel resection and anastomosis were performed. Pathologic finding
revealed metastatic osteosarcoma in small bowel (not shown). Axial CT scan
shows round mass with target pattern and half-moon-shaped hypodense area
(arrow) of fat density, representing mesenteric fat. This pattern is
observed when axis of intussusception is perpendicular to CT beam.
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Fig. 5C. —39-year-old woman with jejunojejunal intussusception caused by
metastatic osteosarcoma. Patient had history of limb salvage operation due to
osteosarcoma of left femur and presented with abdominal pain of sudden onset.
Small-bowel resection and anastomosis were performed. Pathologic finding
revealed metastatic osteosarcoma in small bowel (not shown). CT scan shows
lobulated and highly enhancing mass (arrow) located at tip of
intussusceptum and serving as lead point.
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Duodenojejunal intussusception is rarely encountered because of fixation of
a large portion of the duodenum that prevents telescoping of that segment of
the bowel. Lipoma, adenoma, hamartomatous polyp, and malignant duodenal ulcers
have all been described as lead points for duodenojejunal intussusceptions. CT
can directly show the elongated duodenum with or without the characteristic
targetlike lesion in the proximal jejunum, accompanied by dislocation of the
ampulla of Vater (Figs. 6A and
6B).
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Fig. 6A. —48-year-old woman with Peutz-Jeghers syndrome who presented with
duodenojejunal intussusception caused by hamartomatous polyps. Unenhanced CT
scan shows mesenteric fat, vessels, and intussusceptum (fourth portion of
duodenum and proximal jejunum [arrowheads]) entering intussuscipiens
of jejunum (arrows).
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Fig. 6B. —48-year-old woman with Peutz-Jeghers syndrome who presented with
duodenojejunal intussusception caused by hamartomatous polyps. Radiograph
obtained during small-bowel follow-through shows dilated proximal jejunum.
Contrast material has entered space between intussusceptum and
intussuscipiens, causing coiled spring appearance (arrows), a sign of
intussusception. Note several polypoid lesions (arrowheads) in
gastric antrum and jejunum. Operative findings confirmed two intussusceptions
of duodenojejunal and ileocecal type caused by hamartomatous polyps. Open
polypectomy was performed.
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Retrograde jejunal intussusceptions may occur as postoperative
complications of Roux-en-Y anastomoses (Figs.
7A,
7B,
7C, and
7D). Although the underlying
pathogenesis of the retrograde intussusception is not well known, retrograde
peristalsis without an associated abnormality is the most common cause
[7].
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Fig. 7A. —53-year-old woman who had history of total gastrectomy due to
advanced gastric cancer with retrograde jejunojejunal intussusception caused
by adhesive band. Axial CT scan shows markedly dilated proximal jejunal loop
of intussuscipiens (arrows) and collapsed and enhancing
intussusceptum (arrowheads) continuous to distal jejunum.
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Fig. 7B. —53-year-old woman who had history of total gastrectomy due to
advanced gastric cancer with retrograde jejunojejunal intussusception caused
by adhesive band. Scanogram shows masslike opacity (arrow) suggesting
intussusceptum within dilated proximal jejunal loop.
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Fig. 7C. —53-year-old woman who had history of total gastrectomy due to
advanced gastric cancer with retrograde jejunojejunal intussusception caused
by adhesive band. Sonogram along longitudinal axis of intussusception shows
typical "pseudokidney" sign.
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Fig. 7D. —53-year-old woman who had history of total gastrectomy due to
advanced gastric cancer with retrograde jejunojejunal intussusception caused
by adhesive band. Color Doppler sonogram shows typical target sign and
vascularity of intussusceptum (arrowheads) and intussuscipiens
(arrow), suggesting viable duodenal wall. In operative fields, no
intussusception was found, but multiple adhesive bands were observed around
efferent loops of Roux-en-Y anastomosis; adhesiolysis was performed.
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Enterocolic and Appendiceal Intussusception
The lead point of enterocolic intussusception can be located in the small
bowel, the large bowel (mainly the cecum), or the appendix. A wide variety of
lesions may be responsible for ileocecal intussusception. Benign tumors
including lipoma, inflammatory fibroid polyp, and hamartomatous polyp
(Fig. 8) of the ileum;
malignant tumors such as lymphoma and ileal or cecal cancer; and Meckel's
diverticulum have all been described as lead points for ileocecal
intussusception. Barium study usually reveals a smoothly tapered narrowing of
the terminal ileum, a high position of the cecum, and an intracecal coiled
spring appearance.
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Fig. 8. —48-year-old woman with Peutz-Jeghers syndrome who presented with
ileocecal intussusception caused by hamartomatous polyp (same patient as in
Figs. 3A and
3B). Double-contrast barium
study shows protruding terminal ileal loop with coiled spring appearance
(arrow). Lobulated filling defect is suspected at terminal ileum.
Colonoscopy (not shown) revealed multiple polyps of variable size in colon and
in terminal ileum. Polypectomy was performed, and multiple polyps were
histopathologically confirmed as hamartomatous polyps.
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Of the various ileocolic intussusceptions, appendiceal intussusception is
rare and is difficult to diagnose radiographically. The normal appendix may
transiently intussuscept. Additionally, a variety of appendiceal diseases such
as appendiceal inflammation, infestation, neoplasm, and endometriosis
deposition are recognized as primary causes of appendiceal intussusception,
with appendiceal mucocele as the most common causes of intussusception related
to underlying disease (Fig.
9). Benign and malignant tumors act as lead points of ileocolic
and of cecocolic intussusceptions (Figs.
10A,
10B,
10C,
10D and
11A,
11B,
11C). The lead point of
ileocolic and cecocolic intussusceptions may be evident at the time of
intussusception or only after reduction of the intussusception.
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Fig. 9. —57-year-old woman with ileoappendicocolic intussusception caused by
appendiceal mucocele. On enhanced CT scan, soft-tissue mass with central fatty
component is seen in hepatic flexure. Elongated and well-demarcated mass of
fluid density (arrows) is shown at tip of intussusceptum, and
transverse colon (arrowheads) distal to intussusception is collapsed.
On unenhanced CT (not shown), curvilinear calcification is shown on wall of
cystic lesion. Right hemicolectomy was performed, and microscopic examination
revealed 4 x 6 cm appendiceal mucocele associated with mucinous
cystadenoma (not shown).
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Fig. 10A. —32-year-old man with ileocolic intussusception caused by
inflammatory fibroid polyp of cecum. CT scans reveal two intussuscepta of
terminal ileum (solid straight arrow, A) and of cecum
(arrowheads, A) and one intussuscipiens of ascending colon
(open arrows, A). Note two layers of fat (curved
arrows, A) within intussusceptum resulting in
"double-target" appearance. Homogeneously low-attenuation ovoid
mass (thick arrow, B) serving as lead point is present at tip
of intussusceptum.
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Fig. 10B. —32-year-old man with ileocolic intussusception caused by
inflammatory fibroid polyp of cecum. CT scans reveal two intussuscepta of
terminal ileum (solid straight arrow, A) and of cecum
(arrowheads, A) and one intussuscipiens of ascending colon
(open arrows, A). Note two layers of fat (curved
arrows, A) within intussusceptum resulting in
"double-target" appearance. Homogeneously low-attenuation ovoid
mass (thick arrow, B) serving as lead point is present at tip
of intussusceptum.
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Fig. 10D. —32-year-old man with ileocolic intussusception caused by
inflammatory fibroid polyp of cecum. Specimen from right hemicolectomy shows 4
x 2 x 2 cm protruding mass (arrows) located on cecum (C)
at appendiceal opening (arrowheads). T = terminal ileum.
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Fig. 11B. —71-year-old woman with ileocolocolic intussusception caused by cecal
cancer. Fluoroscopy shows air reduction was performed for diagnosis and
treatment. At first, intussusceptum (arrow) was located on redundant
transverse colon in pelvic cavity. During reduction, intussusceptum migrated
proximally and disappeared.
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Fig. 11C. —71-year-old woman with ileocolocolic intussusception caused by cecal
cancer. Fluoroscopy image shows that after air reduction, eccentric mass
(solid arrow) was identified in cecum on opposite side of ileocecal
valve (open arrow). Colonoscopy (not shown) revealed large mass in
cecum that was confirmed to be adenocarcinoma.
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Large-Bowel Intussusception
Unlike small-bowel intussusception, more than half of large-bowel
intussusceptions are associated with malignant lesions, including primary
(adenocarcinoma and lymphoma) and metastatic disease
[1,
8]. Benign lesions constitute
approximately 30% of intussusceptions and include neoplasms such as lipoma,
GISTs, and adenomatous polyps and other benign conditions like endometriosis
and a previous anastomosis [4]
(Figs. 12A,
12B, and
12C). Idiopathic
intussusception accounts for approximately 10% of intussusceptions of the
large bowel which occur less often than those of the small bowel (20%)
[9].
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Fig. 12A. —63-year-old man with colocolic intussusception caused by lipoma who
had undergone total gastrectomy 5 years previously because of advanced gastric
cancer. CT scan shows intussusception with 6-cm ovoid, hypodense mass
(–90 H, arrows) in tip of intussusceptum.
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Fig. 12B. —63-year-old man with colocolic intussusception caused by lipoma who
had undergone total gastrectomy 5 years previously because of advanced gastric
cancer. Double-contrast barium study shows round filling defect at tip of
cecum.
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Fig. 12C. —63-year-old man with colocolic intussusception caused by lipoma who
had undergone total gastrectomy 5 years previously because of advanced gastric
cancer. Photograph of specimen from right hemicolectomy shows round fatty mass
that was pathologically proven to be lipoma.
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Sigmoidorectal intussusception is a very rare condition. Because of the low
incidence and the rare consideration given to this condition in adults, the
preoperative diagnosis may be difficult. In our study, a 61-year-old man with
a history of total gastrectomy for stomach cancer had metastatic
adenocarcinoma of the rectum as a lead point of sigmoidorectal intussusception
(Figs. 13A,
13B, and
13C).
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Fig. 13A. —61-year-old man with sigmoidorectal intussusception caused by
metastatic adenocarcinoma from gastric cancer who had undergone total
gastrectomy 5 years previously. Series of CT scans show intraluminal sigmoid
mesocolon (solid arrows, A) with mesenteric vessels adjacent
to homogeneously enhanced rectal mass (open arrow, B).
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Fig. 13B. —61-year-old man with sigmoidorectal intussusception caused by
metastatic adenocarcinoma from gastric cancer who had undergone total
gastrectomy 5 years previously. Series of CT scans show intraluminal sigmoid
mesocolon (solid arrows, A) with mesenteric vessels adjacent
to homogeneously enhanced rectal mass (open arrow, B).
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Fig. 13C. —61-year-old man with sigmoidorectal intussusception caused by
metastatic adenocarcinoma from gastric cancer who had undergone total
gastrectomy 5 years previously. Double-contrast barium study shows lobulated
and eccentric mass (arrows) in rectosigmoid junction. Microscopic
findings (not shown) were identical to those of previously described resected
stomach; mass was diagnosed as metastatic adenocarcinoma.
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Rectal intussusception is a concentric invagination of the entire rectum
that progresses toward the anal canal but does not protrude through the anus.
An intussusception seldom leads to total rectal prolapse. Although sometimes
the diagnosis can be made by rectal examination, defecography is the most
useful tool for the diagnosis of rectal intussusception
(Fig. 14).
Conclusion
Intussusception in adults occurs relatively rarely; however, a specific
lead point is identified in more than 90% of cases
[2]. Most intussusceptions in
adults are associated with either acute intestinal obstruction or partial and
recurring obstruction. A correct and timely diagnosis is not only necessary to
avoid the complications of bowel infarction and perforation secondary to
high-grade obstruction but also to resect the underlying lesion that serves as
a lead point. This is particularly important because an underlying malignancy
may first present as an intussusception. Therefore, knowledge of the imaging
spectrum and the clinical features of intussusception is important because
imaging plays a crucial role in the diagnosis and management of these
patients.
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