The Diagnosis and Management of

Adult Intussusception
Dennis G. Begos, MD, Andras Sandor, MD, Irvin M. Modlin, MD, PhD, FACS, New Haven, Connecticut
~ ~.

BACKGROUND: While intussusception is relatively However, more than a century hefore this Cornelius Henrik
common in children, it is a rare clinical entity in Velse had successfully operated on an adult with such a
adults, where the condition is almost always sec- problem “de mutuo intestinorum ingressu.“” Intussuscep-
ondary to a definable lesion. tion, or “introsusception, ” as it was called, was in addition
DATA SOURCES: Thirteen cases of intussusception detailed in 1789 by John Hunter.” Hunter reported 3 cases,
occurring in individuals older than 16 were en- one in a 9-month old, and the other 2 presumably in adults,
countered at our institute between 1981 and although the age is not mcntioncd. One included a ship’s
1994. “cabin boy” with an ileo-ileal intussusception caused by a
RESULTS: Presenting signs/symptoms included round worm. In such patients Hunter recommended bleed-
recurrent bowel obstruction, intermittent pain, ing the patient (to decrease i&mm&m), and inducing
and red blood per rectum. Correct preoperative vomiting “with a view to invert the peristaltic motion of
diagnosis was made in six patients using colon- the containing gut, which will have a tendency to bring the
oscopy, flexible sigmoidoscopy, upper gastroin- intestines into their natural situation.” As in many other
testinal (GI) series and computed tomography states of illness Hunter also eschewed the then-common
(CT). At surgery the lead point was identified in practice of ingesting tnercury for bowel obstruction.
the small intestine in eight cases, in the colon in Diagnosis of adult intussusception is often difficult and is
four cases, and one small intestinal intussuscep- most commonly estabhshed m the operating room, as op-
tion was considered idiopathic. Twelve patients posed to children, who often present with characteristic
underwent laparotomy and one patient was both symptoms and signs of sudden onset of intermittent colicky
diagnosed and treated by colonoscopy alone. pain, vomiting, and bloody mucclid stools. In children, most
CONCLUSIONS: Adult intussusception is an un- cases are primary, and between 40 % to 80% of patients can
usual cause of bowel obstruction. The likelihood he effectively and permanently tre;lted by pneumatic or hy-
of neoplasia, particularly in the colon as a cause, drostatic reduction, which was introduced by Hirschsprung
is high. Operative management is thus almost al- in 1876.” Contrary to the tnan+getnent of the condition in
ways necessary. Am J Surg. 1997;173:88-94. children, treatment in the adult is not always clear cut.
8 1997 by Excerpta Medica, Inc. While most authors agree that surgical resection is man-
datory. the extent of resection and whether or not the in-
tussusception should be reduced before resection is contro-
hile intussusception is relatively common in chil-

W dren, it is infrequently seen in adults. In addition,

intussusception is an inherently different disease
entity when it presents m the adult population because it
versial.

MATERIALS AND METHODS

The records of all patients over age 16 with the diagnosis
is more commonly secondary to an identifiable lesion, and
of intussusception between ]anu,ny 1, 1981 and December
thus reyuires specific treatment often beyond that of the
3 1, 1994 were reviewed. This report evaluates 13 adult pa-
intussusception itself. A useful way of considering this dis-
tients with intussusception at Yale-New Haven Hospital.
ease is by a rule of fives: 5% of all intussusceptions occur in
Patients with rectal prolapse and prolapse of or around an
adults, and it accounts for up to 5% of all cases of bowel
ostomy were excluded. Followup was from 16 months to 14
obstruction in adults.” Of particular note is the observa-
years, and variously included review of office records, con-
tion that approximately 90% of cases are secondary to a
tact with the primary physician. and contact with individ-
definable lesion, while the opposite is true in children.
ual patients.
The first report of intussusception was by Rarbette of Am-
sterdam in 1674.” In 18il Sir Jonathan Hutchinson was the
first to successfully operate on a child with intussusception.“ RESULTS
Demographics
A total of 13 patients were identified who had a diagnosis
From the Gastrointestinal Surgical Pathobiology Research Unit, of intussusception and were older than 16. The average age
Department of Surgery, Yale University School of Medicine, New
of the patients was 47.2 years, with a range of 17 to 81
Haven, Connecticut and the West Haven VA Medical Center, West
Haven, Connecticut. years. Eight were male and five were female.
Requests for reprints should be addressed to Irvin M. Modlin
MD, PhD, FACS, Yale University School of Medicine, Department Presenting Signs/Symptoms
of Surgery, P.O. Box 208062, New Haven, CT 06520-8062.
The tnajority of patients (nine) presented with nonspecific
Manuscript submitted August 4, 1995 and accepted in revised
form March 12, 1996. symptoms and signs of bowel obstruction, including either
nausea, vomiting, abdominal ilLtension, or intertnittent ob-

88 0 1997 by Excerpta Medica, Inc. 0002-9610/97/$17.00

All rights reserved. PII SOOO2-9610(96)00419-9
 1 DIAGNOSING AND MANAGING ADULT INTUSSUSCEPTIONIBEGOS ET AL

stipation. Five patients with this clinical picture presented
relatively acutely, within 24 to 48 hours of the onset. One
of these patients, however, had experienced intermittent
abdominal pain for over 5 years previously without a diag-
nosis. All of these patients had their lead point in the small
bowel: two had jejune-jejunal intussusception, one ileo-il-
eal, one had an ileocolic intussusception, and one had il-
eocecocolic intussusception. Two further patients exhibited
chronic or intermittent obstructive symptoms: one had con-
stipation for several months, and had a sigmoidorectal
tussusception. The other experienced 2 weeks of intermit-
tent symptoms, and colonoscopy revealed a cecocolic
intussusception consequent upon a lipoma of the ileocecal
valve. Two patients presented with obvious obstructive
symptomatology in the postoperative period of a previous
operation. One individual had undergone a splenectomy for
blunt trauma and subsecluently developed an ileocolic in-
tussusception caused by adhesions 30 days later. The second
patient suffered from Zollinger-Ellison syndrome and had
undergone oversewing of a bleeding duodenal ulcer. She
developed an ileo-ileal intussusception i days postopera-
tively. She did, however, exhibit significant hypergastrine-
mia and had been placed on octreotide therapy. Both sub-
stances-gastrin and snmatostatin-are known to exhibit
significant motility effects on the intestines.
Five patients experienced pain as a presenting symptom.
Two had associated obstructive symptoms, and three had
pain as the only presenting symptom. Of this latter group,
one patient had crampy abdominal pain for several months,
with a jejunojejunal intussusception identified on an upper
gastrointestinal (GI) series. The lead point was a jejunal
metastasis from a melanoma. Two patients had experienced
crampy pain for many years; one had an ileocolic intussus-
ception with no etiology evident, and the other had an ileo-
ileal intussusception with a Meckel’s diverticulum as the
lead point. One further patient presented with red blood
per rectum, and sigmoidoscopy revealed a sigmoidorectal
intussusception due to a sigmoid adenocarcinoma.
Location of Intussusception
Nine patients had the lead point of the intussusception in
the small bowel: three in the jejunum and six in the ileum.
The three jejunal lead points resulted in jejune-jejunal in-
tussusception; three of the ileal based intussusceptions were
ileo-ileal, the other three were ileocolic (Table). Two pa-
tients had the lead point in the ileocecal valve resulting in
ileocecocolic intussusception. Two patients had colonic
lead points, both in the sigmoid: one was from a sigmoid
cancer, the other from an anastomosis after a previous sig-
moidectomy. Both of these resulted in sigmoidorectal in-
tussusception. An anatomic or pathologic cause for the in-
tussusception was identified in 12 of the 13 patients; 1 with
an ileal origin was idiopathic. In the small bowel, adhesions
accounted for two lead points, and metastatic melanoma, a
hamartomatous polyp, carcinomatosis, a leiomyosarcoma,
“disordered motility” (in the patient with hypergastrine-
mia), and a Meckel’s diverticulum accounted for one each.
One of the ileocecal intussusceptions was caused by a li-
poma of the ileocecal valve, the other was secondary to
cecal adenocarcinoma. In the colon, one lead point was a
sigmoid cancer, the other was attributed to a mildly nar-
rowed previous sigmoidorectal anastomosis.
The diagnosis was correctly made preoperatively in 6 of
the 13 patients (18%) (Table). Both LO 1oco - 1onic intussus-
ceptions were diagnosed at sigmoi&>scopy. One jejunoje-
junal intussusccption was correctly dl,lgnoscd hy an upper
GI series, and computed tomographic (CT) scanning was
accurate in determining a lejunojejunal and ileocolic in-
tussusception. One patient with an ileocecocc>lic intussus-
ception was both diagnosed and reduced at colonoscopy.
in- Treatment
All hut one patient underwent lapm>tomy (Table). The
exception was ;I patient with ;I cecocolic intussusception
with a polyp of the ileocecal valve as the lead point. Biopsy
revealed this to he a lipoma that was cndoscopically re-
sected and the mtussusception reciuce~l by insufflation.
Eight months after this, she developed a recurrence of the
intussusception, which was once :I~;IIII managed with co-
lonoscopic reduction. In 7 subsequent years of followup,
there has been no further recurrence.
The remainder of the patients underwent a variety of op-
erations. Of patients with jejunum or ileum as the lead point
of the intussusception, all four with tumors as the lead point
and in addition the individual with Idiopathic intussuscep-
tion underwent resection. At operation all had the intus-
susception reduced before resection. The two patients with
intussusception secondary to adhesions underwent adhesi-
olysis without resection of the involved segments. Likewise,
the patient with a Meckel’s diverticulum as the lead point
of intussusception underwent resection of the diverticulum
without formal ileal resection. The patlent with Zollinger-
Ellison syndrome underwent simple reduction. To date
none of these patients have developed recurrent intussus-
ception over a period ranging from 2 to 7 years of followup.
Of the two patients with the ileocccal valve as the lead
point for the intussusception, one is described above (con-
servative colonoscopic management) and the other had a
right hemicolectomy for cecal carcinoma.
Both patients with sigmoidorectal intussusception under-
went sigmoid resection. The individual with the sigmoid
cancer did not have the intussusception reduced before re-
section; the patient with the prior anastomosis as the lead
point did undergo reduction in the operating room before
resection.
DISCUSSION
Intussusception is quite uncommon in adults, hut this re-
port, and others reflecting the experience of a single insti-
tutions are notable for the fact that each have approxi-
mately one to two cases per year. ‘.j,’ ’ Given this fact, it is
predictable that few general surgeons will see tnore than
one or two such patients during their career. Because most
will not he diagnosed before laparotomy, it is important for
the surgeon to be informed in regard to the various treat-
ment options available for this entity.
Pathogenesis and Etiology
The pathomechanism of idiopathic intussusception is ill
understood. There are no clear explanations regarding mo-
tility disorders secondary to either trauma or surgery. In
about 90% of the intussusceptions in adults there is a lead
point, a well definable pathologic abnormality. Peristalsis
and ingested food push the lesion with the adjacent normal

THE AMERICAN JOURNAL OF SURGERY” VOLUME 173 FEBRUARY 1997 89

 IAGNOSING AND MANAGING ADULT INTUSSUSCEPTlONlBEGOS ET AL

TABLE
Pathology, Preoperative Diagnosis, and Management of lntussusception
Type of Preoperative
Lead Point lntussusception Pathology Diagnosis Operative Strategy
Jejunum Jejuno-jejunal (3 pts) Adhesions (1 pt) - Adhesiolysis
Melanoma (1 pt) Upper GI series Reduction/resection
Hamartoma (1 pt) CT Reduction/resection
ileum Ileo-ileal (3 pts) Meckel’s diverticulum (1 pt) - Reduction/divet-ticulectomy
Hypermotility (1 pt) - Reduction/resection
Carcinomatosis (1 pt) - Reduction/resection
lleocolic (3 pts) Idiopathic (1 pt) - Reduction/resection
Leiomyosarcoma (1 pt) CT Reduction/resection
Adhesions (1 pt) - Adhesiolysis
I leocecal valve lleocecocolic (2 pts) Lipoma (1 pt) Colonoscopy Reduction/endoscopic
polypectomy
Cecal carcinoma (1 pt) - Reduction/right hemicolectomy
Sigmoid Sigmoido-rectal (2 pts) Sigmoid carcinoma (1 pt) Flexible sigmoidoscopy Sigmoidectomy
Anastomosis (1 pt) Flexible sigmoidoscopy Reduction/sigmoidectomy

Gi = gastrointestmal; CT = computed tomography.

bowel (intussusceptum), which telescopes into the relaxed leiomyosarcoma-accounted for 3 of 11 (27%) cases in our
intestinal segment distal to it (intussuscipiens). The pre- series.
ferred localizations are the junctions between freely moving Intussusception occurring in the large bowel, on the other
segments and retroperitoneally (eg, the ileocecal region) or hand, is more likely to have a malignant etiology. This to
adhesionally fixed segments.” As the intussusceptum enters a certain extent reflects the nature of the pathology in the
into the intussuscipiens, the mesentery is carried forward large bowel as opposed to the small. In the latter organ,
and is trapped between the overlapping layers of bowel. The neoplasia is a somewhat rare entity. Sanders, et al reviewed
resulting stretching often produces vascular compression. over 350 cases of colonic intussusception, and 68% were
The vascularly compromised bowel becomes edematous, re- noted to be due to a malignant lead point.lh Adenocarci-
sulting in an increased compression of vessels in the mes- noma accounted for 62% of such lesions. More recent series,
entery. Ischemic necrosis of the bowel wall may ensue un- although smaller, show a remarkahly similar frequency, with
less timely intervention is undertaken.14 63% to 66% of cases heing secondary to a malignancy.5m’
There have been several moderate to large series in the In our series, which had two patients with colonic intus-
last 50 years examining the cause of adult intussusceptlon susception, one was due to a sigmoid adenocarcinoma.
(Figure 1).‘,:,4~‘.” While they do not exhibit universal Intussusception of the appendix is a rare and different en-
agreement in terms of management and etiology, there are tity. To date, about 200 cases have been described in the
several consistent features evident in a comparison of their literature.“-‘” Causes of appendiceal intussusception in-
data. As in our series, the majority of cases arose in the elude villous adenoma, mutinous cystadenoma,
small bowel, and the majority of these were secondary to endometriosis, and adenocarcinoma of the appendix besides
benign lesions. Donhauser and Kelly reviewed 665 cases idiopathic cases.‘i,‘9
that had been reported in the literature, and added 12 of The recent experience regarding intussusceptions occur-
their own.’ In 356 instances the pathology was present in ring in patients afflicted with aquired immunodeficiency
the duodenum, jejunum, or ileum. In an additional 95 pa- syndrome (AIDS)‘“-” is worthy of consideration. Such le-
tients the lead point was at the ileocecal valve. Only 111 sions are generally ileal-based and may occur from lym-
colonic cases were reported, and 35 appendiceal. More re- phoma, atypical mycobacterial infection, or other unusual
cent series confirm this general experience.i,7 An exception, inflammatory processes. Such specific pathology culminates
however, was the Mayo Clinic report, which noted an equal in the hypertrophy of Peyer’s patches, or may be idiopathic
incidence of colonic and small bowel intussusception, with and related to chronic diarrhea. The gut disease associated
24 cases of each over a 23-year period.” No explanation for with AIDS reflects a rising trend and one which requires
this discrepancy is readily apparent. careful consideration when evaluating such individuals pre-
A further consistent observation was the nature of the senting with symptomatology consistent with bowel oh-
pathology at each site. In general, the majority of lead struction.
points in the small bowel are benign. Benign neoplasms,
Meckel’s diverticuli, adhesions, and inflammatory lesions Symptoms and Physical Signs
account for the majority of the nonmalignant etiologies. The presenting symptoms of intussusception are nonspe-
Idiopathic or primary intussusception, which accounts for cific and often chronic in adults, as opposed to children. In
8% to 20% of cases, is also more likely to occur in the small our series, although 9 of 12 (75%) patients presented with
bowel. Small bowel malignancy (either primary or meta- obstructive symptoms, only 5 presented acutely. Five pa-
static) may account for 6% to 30% of cases.“2’4m7 Malignant tients (41%) presented with pain-3 patients (25%) had
neoplasms-metastatic melanoma, carcinomatosis, and a pain as their only presenting symptom, 2 in association with

90 THE AMERICAN JOURNAL OF SURGERY@ VOLUME 173 FEBRUARY 1997

 1 DIAGNOSING AND MANAGING ADULT INTUSSUSCEPTIONIBEGOS ET AL

llpoma. *lomyoma,
hemangloma. neurofibrOma

adenomatous polyp

adhoslons

t motlllty disorder

- lelomyosarcoma
I

- adenocarcinoma

MALIGNANT
lymphoma
(58 %)

- lymphossrcoma. lebmyosarcoma

- lipoma, leiomyoma, adenomatour polyp

BENIGN endometriosis (appendkeal)

(29 w
- previous anastomosis

Figure 1. General causes of intussusception in adults, Based on 8 series (including ours), on an overall number of 1048 cases. In the
small intestine the majority of cases are due to benign causes, therefore reduction before resection is recommended when possible. In
the colon, the leading causes are malignant tumors, thus reduction only is a less reasonable strategy.

obstructive symptoms. The pain was not acute, but had
been present from 2 months to 5 years. Most other series
report pain as the most common symptom, being present in
71% to 90% of patients, with vomiting and red blood per
rectum as the next most common symptoms.2~5~’ The most
important characteristic of pain secondary to intussuscep-
tion is its periodic, intermittent nature.
At physical examination abdominal masses have been
variously reported in 24% to 42% of patients.“,’ We noted
a mass in only one of our patients. This individual had a 2
centimeter leiomyosarcoma of the ileum that presented as
an acute event culminating in an ileocecal intussusception.
The identification of a shifting mass, or one which is only
palpable when symptoms are present, is particularly suspi-
cious of an intussusception or volvulus.
Diagnostic Strategies
Because the symptomatology of adult intussusception varies
greatly among individuals it is impossible to define a perfect
diagnostic algorithm. Although the correct diagnosis is often
based upon intraoperative findings, the modern noninvasive
and invasive imaging techniyues can be of significant help in
precisely identifying these lesions preoperatively.
In cases when obstructive symptoms dominate the clinical
picture plain abdominal films may provide important infor-
mation regarding the site of the obstruction. Colonic symp-
toms may be further evaluated by a barium enema. The
characteristic appearance of the intussuscepting bowel on a
barium enema study (when the contrast material fills from
the tip of the lesion) is a cup-shaped filling defect that is
often accompanied by an additional filling defect repre-
senting the leading tumor. Barium in the peripheral sheath
outlines circular bands of crowded haustra in the intussus-
cipiens, giving a spiral or coil-spring appearance.‘3 The ab-
sence of appendiceal filling together with a cecal filling de-
fect in the expected location of the appendix is highly
suggestive but not specific for appendiceal intussusception.
Persistent intussusception of the appendix during the ex-
amination is highly suggestive of any kind of appendiceal
abnormality hecause idiopathic intussusception often re-
duces spontaneously during the examination.24
An upper GI series may reveal an intussusception in the
small intestine. The proximal bowel is often greatly dilated
and there is a sudden beaklike change in the caliber at the
site of obstruction as the central canal of the intussusceptum
fills.” We successfully diagnosed a jejuno-jejunal intussus-
ception caused hy a melanoma using an upper GI series
(Figure 2A).
Ultrasonography has been used to evaluate suspected in-
tussusception both in children and in adults.‘5,L6 The classic

THE AMERICAN JOURNAL OF SURGERYa VOLUME 173 FEBRUARY 1997 91

 Figure 2. (A) Upper GI series revealing a jejune-jejunal intussusception. The proximal bowel is greatly dilated and there is a sudden
beaklike change (arrow) in the caliber of the jejunum at the site of obstruction. (B) CT appearance of an ileocolic intussusception with a
target mass (arrow) and the proximally dilated ileum above that.

features of intussusception include the “target” and “dough- finding of a coil-spring polypoid mass by colonoscopy in an
nut” signs on transverse view and the “pseudokidney sign” individual with long-term symptoms suggests the diagnosis
in the longitudinal view.“-‘” Pracros et al reported 145 of enteric intussusceptioni4 Biopsy of this mass is not rec-
childhood intussusceptions diagnosed in this way.15 Lim et ommended because of the high risk of an extended tissue
al reported that ultrasonography identified the presence, the necrosis in the vascularly compromised intussusceptum.‘4.i4
site, and the cause of 11 out of 11 cases of adult ileocolic Although some authors warn a@nst colonoscopic reduc-
intussusception.‘” B ef ore sonography, plain abdominal ra- tion of an intussusception, Kitamura and colleagues re-
diographs were obtained for all patients and the sono- ported a successful correction of a colocolic intussusception
graphic examiners were aware of the radiographic findings. caused by a lipoma arising from the transverse colon which
Lim advocates using sonography instead of barium enema was later removed by endoscopic polypectomy.35 Eu et al
or CT in patients with suspected lower ileal or ileocecal also reported a successful reduction of an idiopathic ileo-
obstruction or in patients in whom the level of obstruction cecocolic intussusception by air insufflation via the colon
is undefined. In our series we did not use ultrdsonogrdphy. oscope. ” In our series we had two cases of sigmoidorectal
The major limitation of ultrasonography for evaluating intussusception diagnosed by flexible sigmoidoscopy,
acute obstructive symptoms is the presence of air in the whereas one case of cecocolic intussusception, which was
bowel, which leads to poor transmission and difficulties in both diagnosed and corrected at colonoscopy. It should be
image interpretation. noted that a cecal polyp may be mimicked by an intussus-
The characteristic CT features of intussusception include cepted appendix, especially when the appendiceal orifice is
an early target mass with enveloped, excentrically located not identified. Thus, careful attention should be paid to
areas of low density, later a layering effect occurs as a result indications for endoscopic polypectomy in the cecum be-
of longitudinal compression and venous congestion in the cause endoscopically removing such a lesion may be fol-
intussusceptum.““” Iko and colleagues demonstrated the lowed by peritonitis.”
stages of CT appearances of experimentally induced ileo-
cecocolic, cecocolic, and c&colic intussusceptions.” In a Treatment
more recent report Kurtz et al noted that CT evaluation of The correct treatment of adult intussusception is not uni-
intermittent obstructive symptoms led to correct preoper- versally agreed upon. All authors agree that laparotomy is
ative diagnosis in four out of six cases; if the characteristic mandatory, based upon the likelihood of identifying a path-
features are present, they are pathognomic.” In our series ologic lesion. Early reports in the 1950s advocated reducing
CT scanning accurately identified a jejuno-jejunal and an the intussusception before resectionm4 Thus Brayton and
ileocolic intussusception (Figure 2B). Norris proposed that an attempt at hydrostatic reduction
Colonoscopy and flexible sigmoidoscopy are also useful be undertaken in instances of colonic intussusception to
tools to evaluate intussusception especially when the pre- facilitate antibiotic preparation of the bowel prior to sur-
senting symptoms indicate a large bowel obstruction. A gery.4 If hydrostatic reduction were not possible, they ad-

92 THE AMERICAN JOURNAL OF SURGEFW VOLUME 173 FEBRUARY 1997

 1 DIAGNOSING AND MANAGING ADULT INTUSSUSCEPTION/BEGOS ET AL ]

Figure 3. Operative management strategy

vacated that the intussusception not be reduced in the op-
erating room, lest a malignancy be disseminated. This
attitude was subsequently echoed by Sanders and colleagues
who stated, “Because of the dangers of transperitoneal seed-
ing and other disadvantages of exposing and handling
friable, edematous malignant lesion, it is advisable that no
attempt at operative reduction be made.“‘” Weilbaecher et
al in 1971 noted a 24% incidence of malignancy in small
bowel intussusception, and thus espoused an approach that
abrogated reduction of the intussusception but advocated
en bloc resection as the primary operative maneuver.15 A
more selective, and seemingly more rational option of se-
lective reduction before resection has been proposed in
more recent reports.5,h Th ese authors, however, similarly
declined to support reduction of colonic intussusceptions,
based on concerns regarding tumor seeding. It should be
pointed out that while there are theoretic and emotional
concerns in regard to tumor seeding, no rigorous studies
have satisfactorily resolved this question. Simple reduction
is always acceptable in post-traumatic or postoperative in-
tussusception when no other cause can be found in the
boweL3s,”
It may sometimes be difficult to determine if the lead point
of an intussusception of the right colon is ileum, ileocecal
valve, or colon before reducing the lesion. There may thus
be some logic in attempting to reduce intussusceptions in-
volving the right colon, with the intention of avoiding a
potentially unnecessary colectomy. Alternatively, failure to
do this might result in an unnecessarily extensive resection,
and possibly even require a two-stage procedure. In cases
where the bowel is inflamed, ischemic, or friable, it is ad-
visable to not attempt operative reduction, and proceed di-
rectly with resection. Obvious colocolic intussusceptions
should be resected en bloc, without reduction, given the
a high likelihood of malignancy. In patients with small bowel
intussusception, reduction should always be initially at-
tempted unless signs of bowel ischemia or inflammation are
present.
If the diagnosis of intussusception IS made preoperatively
and the patient is partially or completely obstructed but
without clinical, laboratory, or radiographic evidence of
bowel ischemia, a cautious attempt at hydrostatic reduction
may be contemplated. This would allow a limited colon
preparation prior to subsequent surgery and enable a one-
stage procedure to be undertaken. Such a therapeutic strat-
egy is, however, only possible in a highly selected group of
patients.
In small bowel intussuscepticm a selective approach is fea-
sible, although in general resection is advocated.15 In in-
tussusception from adhesions, Meckel’s diverticulum, Peutz-
Jeghers polyps, and other benign polyps, adhesiolysis,
diverticulectomy, or polypectomy are adequate treatments,
providing the bowel is viable (Figure 3). This approach has
been successfully used in our current series, as well as in
those reported hy others.‘-‘,‘@
CONCLUSION
Adult intussusception is an unusual and challenging con-
dition that requires preoperative diagnostic skill, careful
and considerate intra-operative judgment, and appropriate

THE AMERICAN JOURNAL OF SURGERY” VOLUME 173 FEBRUARY 1997 93

 IAGNOSING AND MANAGING ADULT INTUSSUSCEPTION/BEGOS ET AL 1

postoperative followup in order to anticipate a successful 21. Meyerson S, Desai TK, Polidorl G, ct al. A case of intussuscep-
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area of controversy relates to the issue of reduction as op- lYY3;88:303-306.
22. Cappcll MS, Hassan T, Rosenthal S, Mascarenhas M. Gastro-
posed to resection. The current weight of evidence supports
intestinal obstruction due to Mycohacterium uwum intracelluiare RS-
that adult colonic intussusception should be resected en
soclated with the acquired Immunr)~leticiency syndrome. Am J (ias-
bloc, given the likelihood of a neoplastic etiology. Intus-
tro. 1992;87:1823-1827.
susception in children and in the small bowel may be ame- 23. Wiot JF, Spitz HB. Small bowel mtussusccptwn demonstrated
nable to initial reduction if viability criteria are met and no hy oral h,lrium. RadioloW. 1970;97:ihl-166,
neoplastic lesion is evident, 24. Gilsang V. IXsplacement of the appendix m intussuscepnon.
A/R. 1984;142:407-408.
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94 THE AMERICAN JOURNAL OF SURGERY” VOLUME 173 FEBRUARY 1997