What is the appropriate diagnostic and treatment approach for intussusception in adults?

Diagnostic and Treatment Approach for Adult Intussusception

Adult intussusception requires prompt CT imaging for diagnosis and surgical management with en-bloc resection without reduction due to the high likelihood of malignancy as the underlying cause. 1, 2, 3

Clinical Presentation

• Unlike pediatric cases, adult intussusception presents with:
  • Intestinal obstruction symptoms (70-82% of cases) 4, 2
  • Crampy, intermittent abdominal pain (acute, subacute, or chronic)
  • Possible palpable abdominal mass
  • Duration of symptoms ranging from hours to weeks 5

Diagnostic Algorithm

1. Initial Imaging:

   • Abdominal CT scan (90-95% diagnostic accuracy) 1, 2
   • Abdominal ultrasound (60-78% accuracy, higher when palpable mass present) 4, 2
   • Plain abdominal X-ray (recommended as first-line to assess for obstruction) 1

2. Secondary Diagnostic Tools:

   • Colonoscopy for ileocolic and colonic intussusception (100% accuracy for identifying lead points) 2
   • Laboratory tests: Complete blood count, inflammatory markers (CRP, procalcitonin) 1

Classification

• Enteric (small bowel to small bowel): 42% of cases 2
• Ileocolic (small bowel to large bowel): 32% of cases 2
• Colonic (large bowel to large bowel): 26% of cases 2

Treatment Approach

Initial Management

• Intravenous fluid resuscitation
• Nasogastric tube for decompression
• Antiemetics as needed
• Foley catheter to monitor urine output 1

Surgical Management

1. Enteric Intussusception:

   • 62% benign, 38% malignant lead points 2
   • Consider reduction before resection if:
     • Benign etiology is suspected
     • Extensive small bowel resection would be required 2

2. Ileocolic Intussusception:

   • 50% benign, 50% malignant lead points 2
   • En-bloc resection without reduction is preferred 3
   • Right hemicolectomy is typically performed 6

3. Colonic Intussusception:

   • 70% malignant, 30% benign lead points 2
   • En-bloc resection without reduction is strongly recommended 2, 3

Surgical Technique

• Laparoscopic approach for hemodynamically stable patients
• Open surgical approach for unstable patients or complex cases 1
• Assessment of bowel viability using visual inspection or indocyanine green fluorescence angiography 1
• Resection of the underlying lesion (most commonly a tumor) 1

Important Considerations

• 54.5% of adult intussusceptions have a tumor as lead point, with 27.3% being malignant 4
• Attempting reduction before resection in colonic intussusception risks:
  • Tumor seeding
  • Perforation of ischemic bowel
  • Anastomotic complications 2, 3
• Delay in surgical intervention beyond 48 hours significantly increases mortality 1
• Recurrence is rare after appropriate surgical management 4

Pitfalls to Avoid

• Attempting non-operative reduction in colonic intussusception with suspected malignancy
• Delaying surgical intervention when diagnosis is confirmed
• Failing to perform complete oncological resection when malignancy is suspected
• Missing synchronous lesions during surgical exploration

Adult intussusception differs significantly from pediatric cases in etiology, presentation, and management approach, with malignancy being a much more common cause in adults, necessitating a more aggressive surgical approach.