Adult Intussusception: Diagnostic and Therapeutic Approach
Immediate Diagnostic Strategy
CT scan with contrast is the mandatory imaging modality for all suspected adult intussusception cases, achieving 80% sensitivity and nearly 100% specificity while identifying the lead point, complications, and guiding surgical planning 1, 2.
Critical Initial Assessment
Evaluate for surgical emergencies immediately: Look specifically for peritonitis (guarding, rigidity, rebound tenderness), hemodynamic instability despite resuscitation, pneumoperitoneum on imaging, or clinical signs of bowel ischemia (markedly elevated lactate, severe continuous pain, bloody stools) 3.
Assess hemodynamic stability to determine intervention urgency—the 48-hour threshold is critical, as mortality increases significantly with delayed intervention 1, 2.
Recognize that 86-93% of adult cases have an underlying pathologic lesion (malignancy, inflammatory bowel disease, adhesions, Meckel's diverticulum), fundamentally distinguishing adult from pediatric intussusception 1, 2, 4, 5.
Anatomic Classification Matters
Colonic intussusception: 100% have a lead point, with 33-67% being malignant 6, 4.
Small bowel intussusception: 46-54.5% have a lead point, with 27-29% being malignant 6, 7.
Retrograde intussusception: Essentially no pathologic lead points identified 6.
Ileocolic intussusception: All cases in one series were malignant 4.
Surgical Management Algorithm
Formal surgical exploration with bowel resection following oncological principles is the standard approach due to the high malignancy risk 1, 2.
Location-Specific Surgical Technique
Right-sided colonic intussusception: Perform right hemicolectomy with primary anastomosis in stable patients 2.
Left-sided malignant colonic intussusception: Execute segmental resection with primary anastomosis in hemodynamically stable patients without perforation 2.
High-risk patients or those with perforation: Utilize staged operative approach (Hartmann procedure) to mitigate postoperative morbidity 2.
Reduction vs. Resection Decision
For colonic intussusception, resect without reduction because pathology is mostly malignant 4. The guideline evidence strongly supports this approach to avoid tumor seeding and ensure adequate oncologic margins.
For small bowel intussusception, reduction before resection is acceptable when the underlying etiology is suspected to be benign or when resection without reduction would be massive 4. However, resection of the affected segment is recommended as it results in fewer recurrences compared to simple reduction 8, 1.
Operative Technical Considerations
Begin exploration from the ileocecal junction (distal to obstruction) where bowel is less dilated and safer to handle laparoscopically 1, 2.
Assess intestinal viability thoroughly—if ischemia is present, perform surgical resection 8.
Use indocyanine green (ICG) fluorescence angiography to guide resection margins when intestinal perfusion is questionable 8, 1.
Close all mesenteric defects with non-absorbable sutures after reduction to prevent recurrence 8, 1.
Risk Stratification for Lead Points
Patients with small bowel intussusception have higher likelihood of pathologic lead point when:
- Age over 60 years (RR 2.2) 6
- Past history of malignancy (RR 3.7) 6
- Mass visible on preoperative CT scan (RR 2.9) 6
Non-Operative Management (Highly Selective)
Non-operative management may be attempted only when the patient is hemodynamically stable, has no signs of peritonitis or bowel compromise, and has a colonic location amenable to colonoscopic reduction 1.
Strict Criteria and Monitoring
Endoscopic reduction carries high recurrence rates, making it a less favorable option 1, 2.
Mandatory close monitoring for at least 24 hours after reduction is necessary to detect early recurrence 1, 3.
Surgical consultation must be obtained in all cases, even when attempting non-operative management 2, 3.
Absolute Contraindications to Non-Operative Reduction
- Signs of peritonitis present 3
- Hemodynamic instability persisting despite resuscitation 3
- Radiological evidence of perforation (pneumoperitoneum) 3
- Clinical signs of bowel ischemia 3
Special Clinical Scenarios
Post-Bariatric Surgery Intussusception
Immediate surgical intervention is recommended for acute presentations 1. For stable patients with persistent abdominal pain and inconclusive findings, exploratory laparoscopy is mandatory within 12-24 hours 8, 1.
Peutz-Jeghers Syndrome
Elective polypectomy of small bowel polyps >1.5-2 cm (or smaller if symptomatic) prevents intussusception, as these patients have a 50-68% cumulative risk in childhood 1, 2. Surveillance with video capsule endoscopy and MRI enterography should begin at age 8 years 1.
Critical Pitfalls to Avoid
Never delay surgery beyond 48 hours in adults with confirmed intussusception—mortality increases significantly 1, 2.
Do not assume idiopathic etiology given that 86-93% of adult cases have underlying pathology 1, 2.
Avoid simple reduction alone as it results in higher recurrence rates compared to resection 8, 1.
Do not attempt non-operative reduction in colonic cases given the high malignancy rate 4.