Pictorial Essay

Intussusception in Adults: From Stomach to Rectum

Seung Hong Choi1, Joon Koo Han, Se Hyung Kim, Jeong Min Lee, Kyoung Ho Lee, Young Jun Kim, Su Kyung An, Byung Ihn Choi

I ntussusception in adults is rare. It

is estimated to account for only
ing to location and cause and correlate these
with the pathologic findings.
abnormal peristaltic movement, which may
lead to the telescoping of one bowel segment
American Journal of Roentgenology 2004.183:691-698.

5% of all intussusceptions and over the adjacent segment. Intussusception ap-

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, al-
though the reverse is true in the small bowel.
In this article, we describe the characteristic
radiologic features of intussusception accord-
Clinical and Imaging Features
The most common symptoms of intussus-
ception are abdominal pain, nausea, and vom-
iting; less frequent symptoms are melena,
weight loss, fever, and constipation [4].
Symptoms are usually of long duration (sev-
eral 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
pears as a complex soft-tissue mass consisting
of the outer intussuscipiens and the central in-
tussusceptum (Fig. 1). Any tumor acting as the
lead point of an intussusception may be outlined
distal to the tapered lumen of the intussuscep-
tum. Barium reflux in the lumen of the space
between the intussusceptum and intussuscipiens
allows the coiled spring to be visualized. Intus-
susception is well diagnosed on CT, which
shows a pathognomonic bowel-within-bowel
configuration with or without contained fat and
mesenteric vessels [3]. Intussusception appears

Fig. 1.—Schematic drawings of intussusception. Longitudinal and serial cross-sec-

tional diagrams of intussusception show invagination of one segment of gastrointesti-
nal 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.

Received September 3, 2003; accepted after revision May 17, 2004.

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. Address correspondence to J. K. Han (hanjk@radcom.snu.ac.kr).
AJR 2004;183:691–698 0361–803X/04/1833–691 © American Roentgen Ray Society

AJR:183, September 2004 691

 Choi et al.

A B
Fig. 2.—71-year-old woman with gastroduodenal intussusception caused by prolapsed antral mass of early gastric cancer type I.
A, Contrast-enhanced CT scan shows homogeneously enhancing mass (arrows), continuous to antrum, is prolapsed and located on duodenal bulb.
B, 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 × 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.
American Journal of Roentgenology 2004.183:691-698.

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 lon-
gitudinal axis [4]. Sonography can make the di-
agnosis 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 pro-
duced by the mucosa of the intussusception,
which is surrounded by a hypoechoic ring rep-
resenting the walls of both the intussusceptum
and the intussuscipiens [5].
Gastric Intussusception
Gastric intussusception is a rarely docu-
mented 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, adenocarci-
noma, 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

A B
Fig. 3.—48-year-old woman with gastroduodenal intussusception caused by Brunner’s gland hamartoma of pylorus.
A, Double-contrast barium study shows narrow and tapered barium streaks (single arrow) representing intussusceptum. Coiled spring appearance (arrowheads) of duode-
num 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.
B, 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.

692 AJR:183, September 2004

 CT of Intussusception in Adults

the pyloric canal and the duodenum with an
associated lead point (Figs. 2 and 3).
Small-Bowel Intussusception
Although surgical intervention is consid-
ered necessary in intussusception in adults
when patients are symptomatic, many as-
ymptomatic and likely transient intussuscep-
tions may be incidentally detected on CT.
When self-limited, they do not require ther-
apy [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 pol-
yps, congenital lesions such as Meckel’s divertic-
ulum and intestinal duplication, inflammatory
lesions, and trauma. Malignant lesions caus-
American Journal of Roentgenology 2004.183:691-698.
Duodenojejunal intussusception is rarely
encountered because of fixation of a large
portion of the duodenum that prevents tele-
scoping of that segment of the bowel. Li-
poma, adenoma, hamartomatous polyp, and
malignant duodenal ulcers have all been de-
scribed as lead points for duodenojejunal in-
tussusceptions. CT can directly show the
elongated duodenum with or without the
characteristic targetlike lesion in the proxi-
mal jejunum, accompanied by dislocation of
the ampulla of Vater (Fig. 6).
Retrograde jejunal intussusceptions may
occur as postoperative complications of
Roux-en-Y anastomoses (Fig. 7). Although
the underlying pathogenesis of the retro-
grade intussusception is not well known, ret-
rograde peristalsis without an associated
abnormality is the most common cause [7].
sponsible for ileocecal intussusception.
Benign tumors including lipoma, inflamma-
tory 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 de-
scribed as lead points for ileocecal intussus-
ception. Barium study usually reveals a
smoothly tapered narrowing of the terminal
ileum, a high position of the cecum, and an
intracecal coiled spring appearance.
Of the various ileocolic intussusceptions,
appendiceal intussusception is rare and is
difficult to diagnose radiographically. The
normal appendix may transiently intussus-
cept. Additionally, a variety of appendiceal
diseases such as appendiceal inflammation,
infestation, neoplasm, and endometriosis
deposition are recognized as primary causes
of appendiceal intussusception, with appen-
diceal mucocele as the most common causes

ing intussusception in the small bowel in-
clude adenocarcinoma; malignant GIST;
metastasis from various primary sites such as
the lung or breast; malignant melanoma; os-
teosarcoma and lymphoma; and primary
lymphoma (Figs. 4 and 5).
Enterocolic and Appendiceal
Intussusception
The lead point of enterocolic intussuscep-
tion can be located in the small bowel, the
large bowel (mainly the cecum), or the ap-
pendix. A wide variety of lesions may be re-
of intussusception related to underlying dis-
ease (Fig. 9). Benign and malignant tumors
act as lead points of ileocolic and of ceco-
colic intussusceptions (Figs. 10 and 11). The
lead point of ileocolic and cecocolic intus-
susceptions may be evident at the time of

A B

Fig. 4.—71-year-old woman with jejunojejunal intussusception caused

by metastatic malignant melanoma.
A and B, 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 thick-
ened and well enhanced. Central necrotic mass (open arrow, B) serves as
lead point and is located at tip of intussusceptum. Note another small ne-
crotic nodule (curved arrow, A) in proximal portion of intussusception.
C, Radiograph obtained during small-bowel follow-through shows intralu-
minal masses (arrows) at duodenum and proximal jejunum. One of these
(mass in radiopaque circle) shows irregular barium collection in central ul-
ceration resulting in bull’s eye appearance and surrounding coiled spring
appearance (arrowheads).
C

AJR:183, September 2004 693

 Choi et al.

A B

Fig. 5.—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).
A, CT scan shows sausage-shaped mass with well-enhanced portion (arrows),
representing bowel wall of intussuscipiens within intussusceptum at its periph-
American Journal of Roentgenology 2004.183:691-698.

ery 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.
B, Axial CT scan shows round mass with target pattern and half-moon-shaped
hypodense area (arrow) of fat density, representing mesenteric fat. This pat-
tern is observed when axis of intussusception is perpendicular to CT beam.
C, CT scan shows lobulated and highly enhancing mass (arrow) located
at tip of intussusceptum and serving as lead point.

A B

Fig. 6.—48-year-old woman with Peutz-Jeghers syndrome who presented with duodenojejunal intussusception caused by hamartomatous polyps.
A, Unenhanced CT scan shows mesenteric fat, vessels, and intussusceptum (fourth portion of duodenum and proximal jejunum [arrowheads]) entering intussuscipiens of jejunum (arrows).
B, Radiograph obtained during small-bowel follow-through shows dilated proximal jejunum. Contrast material has entered space between intussusceptum and intussus-
cipiens, causing coiled spring appearance (arrows), a sign of intussusception. Note several polypoid lesions (arrowheads) in gastric antrum and jejunum. Operative find-
ings confirmed two intussusceptions of duodenojejunal and ileocecal type caused by hamartomatous polyps. Open polypectomy was performed.

694 AJR:183, September 2004

 CT of Intussusception in Adults

A B
American Journal of Roentgenology 2004.183:691-698.

C D
Fig. 7.—53-year-old woman who had history of total gastrectomy due to advanced gastric cancer with retrograde jejunojejunal intussusception caused by adhesive band.
A, Axial CT scan shows markedly dilated proximal jejunal loop of intussuscipiens (arrows) and collapsed and enhancing intussusceptum (arrowheads) continuous to distal jejunum.
B, Scanogram shows masslike opacity (arrow) suggesting intussusceptum within dilated proximal jejunal loop.
C, Sonogram along longitudinal axis of intussusception shows typical “pseudokidney” sign.
D, 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.

Fig. 8.—48-year-old woman with Peutz-Jeghers syndrome who presented with ileocecal in-
tussusception caused by hamartomatous polyp (same patient as in Fig. 3). 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.
Fig. 9.—57-year-old woman with ileoappendicocolic intussusception caused by appen-
diceal 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 × 6 cm appendiceal mucocele associated with mucinous cystadenoma (not shown).

AJR:183, September 2004 695

 Choi et al.

A B

Fig. 10.—32-year-old man with ileocolic intussusception caused by

inflammatory fibroid polyp of cecum.
A and B, CT scans reveal two intussuscepta of terminal ileum (solid
straight arrow, A) and of cecum (arrowheads, A) and one intussuscip-
iens of ascending colon (open arrows, A). Note two layers of fat
(curved arrows, A) within intussusceptum resulting in “double-tar-
get” appearance. Homogeneously low-attenuation ovoid mass (thick
arrow, B) serving as lead point is present at tip of intussusceptum.
American Journal of Roentgenology 2004.183:691-698.

C, Double-contrast barium study shows columnlike polypoid mass

(arrows) at cecum.
D, Specimen from right hemicolectomy shows 4 × 2 × 2 cm protruding
mass (arrows) located on cecum (C) at appendiceal opening (arrow-
heads). T = terminal ileum.

C D

A B C

Fig. 11.—71-year-old woman with ileocolocolic intussusception caused by cecal cancer.

A, On enhanced CT scan, soft-tissue mass with central fatty component (arrow) is seen in right abdomen.
B, Fluoroscopy shows air reduction was performed for diagnosis and treatment. At first, intussusceptum (arrow) was located on redundant transverse colon in pelvic cav-
ity. During reduction, intussusceptum migrated proximally and disappeared.
C, 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.

696 AJR:183, September 2004

 CT of Intussusception in Adults

A B

Fig. 12.—63-year-old man with colocolic intussusception caused by lipoma

who had undergone total gastrectomy 5 years previously because of ad-
vanced gastric cancer.
A, CT scan shows intussusception with 6-cm ovoid, hypodense mass (–90 H, ar-
rows) in tip of intussusceptum.
B, Double-contrast barium study shows round filling defect at tip of cecum.
C, Photograph of specimen from right hemicolectomy shows round fatty mass
American Journal of Roentgenology 2004.183:691-698.

that was pathologically proven to be lipoma.

A B

Fig. 13.—61-year-old man with sigmoidorectal intussusception caused by

metastatic adenocarcinoma from gastric cancer who had undergone total
gastrectomy 5 years previously.
A and B, Series of CT scans show intraluminal sigmoid mesocolon (solid
arrows, A) with mesenteric vessels adjacent to homogeneously en-
hanced rectal mass (open arrow, B).
C, Double-contrast barium study shows lobulated and eccentric mass (ar-
rows) in rectosigmoid junction. Microscopic findings (not shown) were
identical to those of previously described resected stomach; mass was di-
agnosed as metastatic adenocarcinoma.
C

AJR:183, September 2004 697

 Choi et al.

tified in more than 90% of cases [2]. Most in-

tussusceptions 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 ob-
struction but also to resect the underlying le-
sion that serves as a lead point. This is
particularly important because an underlying
malignancy may first present as an intussus-
ception. Therefore, knowledge of the imag-
ing spectrum and the clinical features of
intussusception is important because imag-
ing plays a crucial role in the diagnosis and
management of these patients.
Fig. 14.—88-year-old woman who presented with fecal incontinence. Defecogram shows concentric invagina-
tion (arrows) of rectal intussusception during defecation.
References
1. Azar T, Berger DL. Adult intussusception. Ann
intussusception or only after reduction of the and the rare consideration given to this con- Surg 1997;226:134–138
American Journal of Roentgenology 2004.183:691-698.

intussusception.
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 intussuscep-
tions and include neoplasms such as lipoma,
GISTs, and adenomatous polyps and other
benign conditions like endometriosis and a
previous anastomosis [4] (Fig. 12). Idiopathic
intussusception accounts for approximately
10% of intussusceptions of the large bowel
which occur less often than those of the small
bowel (20%) [9].
Sigmoidorectal intussusception is a very
rare condition. Because of the low incidence
dition 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 adenocarci-
noma of the rectum as a lead point of sig-
moidorectal intussusception (Fig. 13).
Rectal intussusception is a concentric in-
vagination of the entire rectum that
progresses toward the anal canal but does not
protrude through the anus. An intussuscep-
tion seldom leads to total rectal prolapse. Al-
though 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 iden-
2. Agha FP. Intussusception in adults. AJR
1986;146:527–531
3. Warshauer DM, Lee JK. Adult intussusception
detected at CT or MR imaging: clinical-imaging
correlation. Radiology 1999;212:853–860
4. Gayer G, Zissin R, Apter S, Papa M, Hertz M.
Pictorial review: adult intussusception—a CT di-
agnosis. Br J Radiol 2002;75:185–190
5. Cerro P, Magrini L, Porcari P, De Angelis O.
Sonographic diagnosis of intussusceptions in
adults. Abdom Imaging 2000;25:45–47
6. Lvoff N, Breiman RS, Coakley FV, Lu Y, Warren
RS. Distinguishing features of self-limiting adult
small-bowel intussusception identified at CT. Ra-
diology 2003;227:68–72
7. Waits JO, Beart RW Jr, Charboneau JW. Jejunogas-
tric intussusception. Arch Surg 1980;115:1449–1452
8. Nagorney DM, Sarr MG, McIlrath DC. Surgical
management of intussusception in the adult. Ann
Surg 1981;193:230–236
9. Gold BM, Meyers MA. Progression of Menetrier’s
disease with postoperative gastrojejunal intussus-
ception. Gastroenterology 1977;73:583–586

698 AJR:183, September 2004