Ileocolic intussusception in an adult: A rare case series and review of literature

Shardool Vikram Gupta; Jitendra Kumar; Divya Sharma; Siddharth Khemka

doi:10.4103/ijcs.ijcs_13_21

ORIGINAL ARTICLE

Year : 2022 | Volume : 5 | Issue : 1 | Page : 5-9

Ileocolic intussusception in an adult: A rare case series and review of literature

Shardool Vikram Gupta¹, Jitendra Kumar¹, Divya Sharma², Siddharth Khemka¹
¹ Department of Surgery, Dr. B. S. A. Medical College and Hospital, New Delhi, India
² Department of Pathology, Dr. B. S. A. Medical College and Hospital, New Delhi, India

Date of Submission	23-May-2021
Date of Acceptance	06-Jun-2021
Date of Web Publication	12-Sep-2022

Correspondence Address:
Dr. Jitendra Kumar
Department of Surgery, Dr. B. S. A. Medical College and Hospital, Sector – 6, Rohini, New Delhi - 110 085
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijcs.ijcs_13_21

Abstract

Background: Intussusception is commonly presented in children, whereas in adult, it is a rare finding. Classic presentation of ileocolic intussusception seen in children is missing in the adult population. So many times, adult patient of ileocolic intussusception presenting with atypical symptoms becomes a diagnostic dilemma which gets confirmed only after the surgery. Here, we are presenting a rare case series of ileocolic intussusception managed in our tertiary care center during the past 5 years. We are also discussing the available literature in the context of our clinical findings, possible etiopathogenesis, and management of this rare presentation. Materials and Methods: We are reporting here rare seven cases diagnosed with ileocolic intussusception and were managed successfully at our tertiary care hospital over span of the past 5 years. Data of all these cases (n = 7) were collected and analyzed retrospectively. Results: Among the seven patients, six were male (85.71%). The mean age of presentation was 59.1 years of age (range: 45–74 years). Most patients (85.71%) had abdominal pain as main presenting complaint. Three patients (42.85%) were diagnosed primarily on colonoscopy, whereas the rest four were diagnosed on contrast-enhanced computed tomography abdomen. Most patients had pathological lead points such as gastrointestinal stromal tumor (n = 2), carcinoma cecum (n=1), adenovillous adenoma (n=1), and Non-Hodgkin's lymphoma (n = 1). Most of the patients (n=6) needed surgical exploration. Conclusion: Adult ileocolic intussusception is usually associated with pathological malignant lead points. Surgical explorations are mainstay of treatment in these cases.

Keywords: Ileocecal, ileocolic, intussusception, laparoscopic-assisted hemicolectomy, lead point

How to cite this article:
Gupta SV, Kumar J, Sharma D, Khemka S. Ileocolic intussusception in an adult: A rare case series and review of literature. Indian J Colo-Rectal Surg 2022;5:5-9

How to cite this URL:
Gupta SV, Kumar J, Sharma D, Khemka S. Ileocolic intussusception in an adult: A rare case series and review of literature. Indian J Colo-Rectal Surg [serial online] 2022 [cited 2023 Mar 29];5:5-9. Available from: https://www.ijcrsonweb.org/text.asp?2022/5/1/5/355937

Introduction

Intussusception is a condition characterized by telescoping of one intestinal segment into another. The term “intussusception” was first coined by John Hunter, while the first successful reduction was reported by Hutchinson.^[1],[2] According to its site of origin and segment of bowel involved, it may be either enteric, ileocolic, ileocecal, or colonic. In ileo-colic intussusception, distal ileum and/or cecum invaginates into distal colonic segment. Overall, intussusception of the bowel is much more common in children than adult.^[3] Etiopathogenesis and clinical presentation of intussusception are also quite different in children than in the adult.^[4] Most of the time causes of intussusception remain unknown in children, but in adult, it is almost always due to the presence of pathological lead point.^[5],[6] Unlike in children, the presentation of intussusception in adult remains atypical and diagnosis is not always straightforward. In view of rarity and its nonspecific presentation, it always becomes challenging for the surgeon to diagnose and manage a case of intussusception presented in adult. Most adult patients with ileocolic intussusception require operative intervention, while small bowel intussusception in pediatric population may be managed by nonoperative interventions.^[7]

We present here a case series of seven adult patients diagnosed with rare ileocolic intussusception which was managed successfully during the past 5 years at our tertiary care teaching institute in New Delhi. We are also discussing existing literature with special reference to various aspects such as lead point, diagnostic modality, and treatment strategy, especially in context to our findings.

Materials and Methods

This is a retrospective study on cases diagnosed with ileocolic intussusception and who were treated over span of 5 years between January 2015 and December, 2020.

There were seven adult patients diagnosed with ileocolic intussusception who were treated at our tertiary care teaching hospital during aforementioned period. All the relevant data of the patients were collected from medical record department and studied retrospectively.

All the adult patients >18 years of age who were diagnosed with ileocolic intussusception were included in the study. Apart from age and diagnosis, there was no other inclusion or exclusion criterion for the selection of the patients. We collected all the demographic and epidemiological profiles along with clinical details, treatment provided, and details of response by the patients in terms of recovery and outcome.

Results

Among the seven patients, six were male (85.71%). The mean age of presentation was 59.1 years of age (range: 45–74 years). Most patients (85.71%) had abdominal pain as main presenting complaint, while one patient had abdominal lump and anorexia without any abdominal pain. One of the younger patients (age: 32) had recurrent episodes of subacute intestinal obstruction.

Three patients (42.85%) were diagnosed primarily on colonoscopy, whereas the rest four were diagnosed on contrast-enhanced computed tomography (CECT) of the abdomen. Three out of these four had classical target sign [Figure 1] and [Figure 2]. In patients diagnosed with colonoscopy, invagination of ileum into colon was visible intraluminal. One of these patients had growth in cecum intraluminally which turned out to be carcinoma cecum on histopathological examination of colonoscopic biopsy.

Figure 1: Contrast-enhanced computed tomography abdomen (axial section) showing target sign in ileocolic intussusception

Click here to view

Figure 2: Contrast-enhanced computed tomography abdomen (coronal section) showing ileocolic intussusception

Click here to view

Most of the patients (n = 6) required surgical exploration, while in one patient colonoscopic pneumatic reduction of intussusception was possible. Two patients (28.57%) underwent laparoscopic-assisted right hemicolectomy, while four patients (57.14%) had traditional open right hemicolectomy [Figure 3], [Figure 4], [Figure 5]. The patient, in which colonoscopic reduction was possible, had lipoma as a lead point which was confirmed in histopathological examination of colonoscopic biopsy specimen.

Figure 3: Laparoscopic image showing ileum intussuscepting into the colon

Click here to view

Figure 4: Laparoscopic image showing mass in hepatic flexure region with empty transverse colon

Click here to view

Figure 5: Laparotomy image showing ileum intussuscepting into the colon (note appendix being held by Babcock's forceps)

Click here to view

Two patients had ileal gastrointestinal stromal tumor (GIST) as lead point. The elderly patient (age: 74) presenting with abdominal lump and anorexia had carcinoma cecum as a pathological lead point. One of the patients had no identifiable lead point in imaging, intraoperative evaluation, and postoperative histopathological examination. In the remaining two patients, one had adenovillous adenoma and other had non-Hodgkin's lymphoma as a lead point of ileocolic intussusception [Table 1].

Table 1: Details of the cases of study population

Click here to view

Discussion

In children, ileocolic intussusception is mostly primary (idiopathic) or due to benign etiology, while in adults, it is due to a pathological lead point. In around 66% of the cases, the pathological lead point may be malignancy as suggested in review by Marinis et al.^[8] and Tan et al.^[4] Various details in respect of ileocolic intussusception published so far in the available literature are summarized in [Table 2].

Table 2: Summary of various details in respect of ileocolic intussusception published so far and available in the existing literature

Click here to view

Rathore et al. described two cases of ileocolic intussusception in their cases series.^[9] Lead point in these two cases was lymphoma and suture knot from a recent bowel anastomosis. They suggested that the presentation of these cases may not be acute and barium enema may not be able to diagnose this condition. They performed right open hemicolectomy in these two cases.

Green et al. described a case of ileocolic intussusception in a middle-aged female where lead point was formed by low-grade appendiceal mucinous neoplasm.^[10]

Siow et al. described two cases with lead points of typhoid colitis and hyperplastic Peyer patches.^[11] In case series by Shenoy, the pathological lead points were lipoma, ileal carcinoid, tubulovillous adenoma, and GIST, respectively.^[12]

Honjo et al. in their retrospective review described 22 patients of ileocolic intussusception.^[13] Most of the patients had pathological lead points which were malignant in majority of patients. These included six patients with cecal cancer and two with malignant lymphoma. There were benign tumors as a lead point (one myxoma of the appendix, one submural lipoma, and two cystomyxomas of the appendix).

Ibrahim et al. described the presence of prior appendectomy scar and carcinoma cecum as lead point in case series of two patients of ileocolic intussusception, while Khan et al. demonstrated the presence of benign submucosal lipoma of cecum as pathological lead point in their case report.^[15],[16] In a case report of ileocolic intussusception by Wong et al., they could not identify any lead even after extensive investigations such as CECT abdomen, colonoscopy, and contrast enema.^[17]

We also had similar observations in our study. We had five (71.4%) cases with malignant pathological lead point.

The investigation of choice for diagnosis of ileocolic intussusception is CECT abdomen with diagnostic accuracy of 58%–100%.^[18] The characteristic feature is the presence of “target sign” or “sausage shaped mass.”^[19],[20] It also helps in identifying location of intussusception or any mass lesion as lead point. Shenoy reported four cases with ileocolic intussusception where CECT abdomen and colonoscopy were main diagnostic investigations.^[12] Honjo et al. in their retrospective review of 22 patients found that computed tomography was able to correctly diagnose in 93.18% (41/43) of cases, while colonoscopy was detecting 96.15% (25/26) patients correctly.^[13]

Colonoscopy may demonstrate the presence of inverted ileum in the colon or mass protruding through the ileocecal valve, the presence of a lead point, and help in obtaining biopsy in suspected malignancy. Plain X-ray and barium enema may not be reliable.^[14] In the current study, the CECT abdomen was more reliable as a sole diagnostic tool and in 57.1% of patients, it was primary diagnostic modality.

Surgical exploration remains the treatment of choice in adult ileocolic intussusception.^[21] Most of the pediatric ileocolic intussusception can be managed conservatively (~80%) by hydrostatic or pneumatic reduction, while adults usually require surgical exploration.^[8],[22]

Siow et al. described two cases of ileocolic intussusception which were managed by laparoscopic-assisted right hemicolectomy, while in a case series by Shenoy, all four patients underwent open right hemicolectomy.^[11],[12] In a case report by Melcher and Safadi, patient presented in emergency as small bowel obstruction and underwent right open hemicolectomy in emergency setting.^[23] In this study, we also had majority of patients requiring surgical exploration. Two patients (28.57%) underwent laparoscopic-assisted right hemicolectomy, while four patients (57.14%) had traditional open right hemicolectomy.

Conclusion

Ileocolic intussusception in adult patients presents usually with recurrent abdominal pain. The lead point is usually pathological and associated with malignant etiology commonly. The mainstay of treatment remains surgical exploration with majority requiring right hemicolectomy. Laparoscopic-assisted hemicolectomy is also feasible and safe alternative to open surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Hunter J. On introsusception. In: Palmer JF, editor. The works of John Hunter. London: FRS London; 1837. p. 587-93.
2.	Hutchinson J. A successful patient of abdominal section for intussusception. Proc R Med Chir Soc 1873;7:195-8.
3.	Aydin N, Roth A, Misra S. Surgical versus conservative management of adult intussusception: Case series and review. Int J Surg Case Rep 2016;20:142-6.
4.	Tan KY, Tan SM, Tan AG, Chen CY, Chng HC, Hoe MN. Adult intussusception: Experience in Singapore. ANZ J Surg 2003;73:1044-7.
5.	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.
6.	McRae JE, Quinn HE, Saravanos GL, et al. Paediatric Active Enhanced Disease Surveillance (PAEDS) annual report 2016: Prospective hospital-based surveillance for serious paediatric conditions. Commun Dis Intell (2018). 2019;43:10.33321/cdi.2019.43.5. Published 2019 Feb 1. doi:10.33321/cdi.2019.43.5.
7.	Weilbaecher D, Bolin JA, Hearn D, Ogden W 2^nd. Intussusception in adults. Review of 160 cases. Am J Surg 1971;121:531-5.
8.	Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, et al. Intussusception of the bowel in adults: A review. World J Gastroenterol 2009;15:407-11.
9.	Rathore MA, Andrabi SI, Mansha M. Adult intussusception–A surgical dilemma. J Ayub Med Coll Abbottabad 2006;18:3-6.
10.	Green N, Krantz W, Tadros A. Adult Ileocolic Intussusception from the Appendix. Case Rep Emerg Med. 2019;2019:3272618. Published 2019 Dec 9. doi:10.1155/2019/3272618.
11.	Siow SL, Mahendran HA. A case series of adult intussusception managed laparoscopically. Surg Laparosc Endosc Percutan Tech 2014;24:327-31.
12.	Shenoy S. Adult intussusception: A case series and review. World J Gastrointest Endosc 2017;9:220-7.
13.	Honjo H, Mike M, Kusanagi H, Kano N. Adult intussusception: A retrospective review. World J Surg 2015;39:134-8.
14.	Smith DS, Bonadio WA, Losek JD, Walsh-Kelly CM, Hennes HM, Glaeser PW, et al. The role of abdominal x-rays in the diagnosis and management of intussusception. Pediatr Emerg Care 1992;8:325-7.
15.	Ibrahim D, Patel NP, Gupta M, Fox JC, Lotfipour S. Ileocecal intussusception in the adult population: Case series of two patients. West J Emerg Med 2010;11:197-200.
16.	Khan MN, Agrawal A, Strauss P. Ileocolic Intussusception-A rare cause of acute intestinal obstruction in adults; Case report and literature review. World J Emerg Surg 2008;3:26.
17.	Wong TY, Higashi K, Horiguchi J. Treatment of adult idiopathic ileocolic intussusception with non-operative reduction under fluoroscopic guidance. Gastroenterol Hepatol Endosc GHE 2398-3116 2016;1:88-9.
18.	Azar T, Berger DL. Adult intussusception. Ann Surg 1997;226:134-8.
19.	Al-Radaideh AM, Omari HZ, Bani-Hani KE. Adult intussusception: A 14-year retrospective study of clinical assessment and computed tomography diagnosis. Acta Gastroenterol Belg 2018;81:367-72.
20.	Gollub MJ. Colonic intussusception: Clinical and radiographic features. AJR Am J Roentgenol 2011;196:W580-5.
21.	Omori H, Asahi H, Inoue Y, Irinoda T, Takahashi M, Saito K. Intussusception in adults: A 21-year experience in the university-affiliated emergency center and indication for nonoperative reduction. Dig Surg 2003;20:433-9.
22.	Barussaud M, Regenet N, Briennon X, de Kerviler B, Pessaux P, Kohneh-Sharhi N, et al. Clinical spectrum and surgical approach of adult intussusceptions: A multicentric study. Int J Colorectal Dis 2006;21:834-9.
23.	Melcher ML, Safadi B. Ileocolic intussusception in an adult. J Am Coll Surg 2003;197:518.