What is the management of intussusception in adults?

Management of Intussusception in Adults

Surgical exploration via laparoscopy or laparotomy is the recommended management for adult intussusception due to the high risk of incarceration, strangulation, and mortality if treatment is delayed beyond 48 hours. 1

Diagnostic Approach

• CT scan is the imaging modality of choice to confirm diagnosis and identify potential complications in hemodynamically stable patients 1, 2
• Evaluate for signs of peritonitis, strangulation, or bowel ischemia, which necessitate immediate surgical intervention 2
• Assess hemodynamic stability to determine urgency of intervention 2

Treatment Algorithm

Initial Management

• Fluid resuscitation to restore intravascular volume and promote physiological stability 1
• Initiate antimicrobial therapy once intussusception is diagnosed or suspected 1
• Surgical consultation should be obtained in all cases, even when considering non-operative management 2

Surgical Management

• Surgical exploration is recommended as the primary treatment due to:
  • High risk of incarceration and strangulation 1
  • Significant mortality increase if intervention is delayed beyond 48 hours 1
  • High rate of underlying pathology (86-93% of cases have a definable lesion) 3, 4

Approach Based on Location:

1. Enteric (Small Bowel) Intussusception:

   • Consider gentle manual reduction followed by resection if benign etiology is suspected 5, 4
   • Malignancy rate is approximately 22.5-29% 5, 4

2. Ileocolic Intussusception:

   • En bloc resection without reduction is preferred due to high malignancy rate (36.9-100%) 5, 4

3. Colonic Intussusception:

   • En bloc resection without reduction is recommended due to high malignancy rate (33-46.5%) 5, 6, 7
   • Avoid reduction to prevent potential intraluminal seeding or venous tumor dissemination 5

Special Considerations for Post-Bariatric Surgery Intussusception

• Pathophysiology involves modified intestinal motility, staple lines, and anatomic peculiarities 1
• Classification: Type I (afferent loop), Type II (efferent loop), or Type III (combined) 1
• Treatment options include:
  • Resection of the invaginated segment (preferred to avoid recurrence) 1
  • Reconstruction of jejuno-jejunostomy if involved 1
  • Consider anchoring techniques (Noble enteropexy) or conversion to other bariatric procedures in selected cases 1

Non-operative Management

• May be considered only in highly selected cases:
  • Hemodynamically stable patients 2
  • No signs of peritonitis or bowel compromise 2
  • Endoscopic expertise readily available 2
• Endoscopic reduction carries high recurrence risk 1, 2
• Close monitoring for at least 24 hours after reduction is necessary 2
• Immediate surgical intervention if:
  • Non-operative reduction fails 2
  • Patient becomes hemodynamically unstable 2
  • Signs of peritonitis develop 2

Pitfalls and Caveats

• Adult intussusception differs significantly from pediatric cases, with higher rates of pathologic lead points 3
• Delay in surgical intervention beyond 48 hours significantly increases mortality 1
• Attempting reduction in colonic intussusception risks tumor seeding if malignancy is present 5, 7
• Post-operative monitoring is essential as complications occur in approximately 22.1% of cases 5