Selected Articles from the
Journal Abdominal Surgery

This article originally appeared in the Spring, 2007 issue of the Journal.

Colo-Colonic Intussusception in the Adult: Case Report and Literature Review

Mohammed Hassan MD
Kevin Powell MD
George Kerlakian MD
Department of Surgery, Good Samaritan Hospital
Cincinnati, Ohio

Correspondence To:
Mohammed Hassan, MD
C/o Amy Engel
Hatton Research 11-J
Good Samaritan Hospital
375 Dixmyth Ave.
Cincinnati, Ohio 45220
(513) 872-3543
Fax: (513) 872-1549
amy_engel@trihealth.com

ABSTRACT
A 44-year-old African-American female presented with an eight-day history of intermittent abdominal pain accompanied by intermittent hematochezia and mucous per rectum. On initial examination, she was found to have a mildly distended, non-tender abdomen. Work-up included computed tomography which demonstrated a colo-colonic intussusception of the ascending colon and a lead point lesion suspicious for a neoplasm. The patient required an exploratory laparotomy which revealed a large, well-defined lesion in the ascending colon. The lesion was successfully resected and the patient had a rapid postoperative recovery with complete resolution of symptoms. Histopathologic evaluation of the specimen identified a highly dysplastic adenoma. Adult intussusceptions are uncommon and colo-colonic intussusceptions with a benign neoplasm lead point are rare. A review of the literature is presented.

INTRODUCTION
Intussusception of the adult is prevalent across a wide range of ages from the second to ninth decade of life ^[1] without a strong sex predilection^[2,3,4]. Adult intussusceptions often present with nonspecific chronic or subacute symptoms, possibly related to intermittent obstruction caused by the intussusception ^[3]. In one series, the mean duration of symptoms tended to be longer in patients with benign lesions or enteric intussusceptions than those with malignant lesions or colonic intussusceptions ^[5]. Symptoms are variable mostly presenting with crampy abdominal pain (75-85% of patients), nausea, and vomiting. Diarrhea, constipation, hematochezia, and palpable abdominal mass are less common ^[3,6,7].

CASE REPORT
A 44-year-old African-American female with no significant medical history presented with an eight-day history of intermittent, diffuse abdominal pain that was crampy in nature. These episodes were accompanied by nausea, intermittent hematochezia, and mucous per rectum which alternated with regular bowel movements. She denied fever, diarrhea, constipation, weight loss, or similar previous episodes. Her pain on presentation was decreased since the start of her symptoms. She denied recent antibiotic use, sick contacts, recent travel or family history of inflammatory bowel disease.

Her past medical history included laparoscopic uterine cystectomy 22 years ago and an IUD placement nine year ago. She was not on any current medications, and denied any allergies. Her last menstrual period was three weeks ago.

On exam, the patient’s vitals were stable and she was afebrile. She was in moderate distress during intermittent pain episodes. Her abdomen was soft, mildly distended, and non-tender. Her rectal exam demonstrated good rectal tone, and was guaiac positive.

Laboratory results were all within normal limits, including a white blood cell count of 8.2, with no left shift or bandemia, hemoglobin of 10.9, and a hematocrit of 37. Her renal panel was significant for a potassium level of 3.0, and her liver function tests were all normal.

An abdominal X-ray showed a non-specific gas pattern, and CT scan with oral and intravenous contrast demonstrated a colo-colonic intussusception with ascending colon infolding into transverse colon with a 3-4 cm low attenuation density visualized at the lead point that was

Extraluminal factors include adhesions that bind one side of the bowel and cause a focal area of abnormal peristalsis or kinking, inflamed Meckel’s diverticulum, or appendix.

Most intussusceptions occur in the direction of normal peristalsis, yet retrograde intussusceptions still do occur. Intussusceptions are classified by their location in the bowel. Fifty-two percent occur in the small bowel, with the majority being enteroenteric (39%) and some being ileocolic (13%). Colonic intussusceptions made up 38% with 17% ileocolic, 17% colocolic, and 4% appedicocecal.^{[ 6,10, 11,12]}

A recent study of intussusception in adults detected by CT or MR imaging demonstrated 88% of the cases to be enteroenteric and only 12% to be involving the colon. ^[13] Neoplasia constitutes two thirds of adult intussusceptions with malignant lesions making up approximately 60% of all neoplasms. These numbers are higher in the large bowel. A review of adult cases in 1976 showed that 69% of colonic intussusceptions had a neoplastic lead point with 70% of them being malignant^[14]. These results were supported with similar or somewhat higher numbers ^{[3,4,7,11,12,15,16, 17]}. In one series, patients with malignant colonic intussusceptions were more likely to have melena or guaiac- positive stools ^[16].

Primary adenocarcinoma is the most common malignancy resulting in intussusception. Other malignancies such as leiomyosarcomas, lymphosarcomas and metastases have also been reported [6,10,11,12].

In the small bowel, neoplasms and malignancy are less common. The same review of cases in 1976 demonstrated that 57% of intussusceptions in the small bowel were secondary to neoplasms with only 30% being malignant ^[14]. The most common malignant lead point was a metastasis with melanoma being the most frequent primary neoplasm. Metastatic disease secondary to squamous cell lung carcinoma, renal cell carcinoma and colon cancer have also been seen. Primary small bowel adenocarcinomas and leiomyosarcomas are less common but have been reported ^{[3,6,10,11,12,16]}.

Benign tumors make up 25% of adult intussusceptions etiology. Adenomatous polyps and lipomas are the most common in the colon. Peutz-Jehgers polyps and lipomas are most common in the small bowel. ^{[3,6,10,11,12,16]} suspicious for a mass. There was no lymphadenopathy, free air or obstruction pattern noted (Figure 1).

The patient was taken to surgery for a midline incision and right hemicolectomy. Liver cysts were palpable and no discrete nodules suspicious for metastatic disease were noted. There was a large intracolic firm mass not extending into surrounding structures. The right colon was opened on the side table demonstrating the culprit lesion (Figure 2).

Postoperatively, the patient was stable and tolerating a diet. She was discharged on postoperative day three without any complications. Pathology demonstrated an ulcerated adenoma that was highly dysplastic. Nineteen lymph nodes were obtained and all were negative for malignancy.

DISCUSSION
Intussusception is primarily a disease of childhood, and a leading cause of intestinal obstruction in children ^[8]. Approximately 5% to 16% of intussusceptions in the western world occur in adults ^[2,3,6,9]. The two processes differ in cause, presentation, diagnosis and treatment.

In both ages of intussusception, the etiology may be intraluminal, mural or extraluminal.^[5] During intussusception caused by an intraluminal lesion, a lead point is pulled forward by peristalsis and drags the attached bowel wall segment with it. The classic etiologies are adenomatous polyps and lipomas.

In mural etiology, there is a focal bowel wall area that does not contract normally, allowing the peristaltic forces to transform the diseased segment into a lead point resulting in intussusception. Examples here include celiac disease, sessile malignancies, local inflammation, surgical suture lines, and lymphoid hyperplasia.

Figure 1 CT scan of colo-colonic intussusception

Figure 2 Lesion Non-neoplastic etiologies of adult intussusception constitute 30% of colonic intussusception. Those include inflammatory disease in the colon or appendix, lymphoid hyperplasia, postoperative anastomosis and suture lines. ^{[3,4,7,11,15,16]} These etiologies are more common in the small bowel, with postoperative changes and adhesions as well as Meckel’s diverticula are the two most common nonneoplastic etiologies in recent studies ^{[3,4,7,11,15,16, 17]}. Idiopathic primary intussusception is relatively uncommon making up on average 16% of small bowel and less than 5% of large bowel etiologies.

A recent study using CT or MR imaging to diagnose intussusception rather than surgical diagnosis found an increased rate of idiopathic transient small bowel intussusception approaching 50%, most likely due to transient peristaltic dysfunction and only discovered due to widespread use of CT^[13]. This study suggested that unlike fixed lesions documented in surgical series, transient intussusceptions do not necessarily require an aggressive work-up ^[13,18].

Figure 1 CT scan of colo-colonic intussusception Figure 2 Lesion

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