For citation purposes: Ongom PA, Kijjambu SC. Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management. OA Emergency Medicine 2013 Aug 01;1(1):3.

Review

 
Reflections on Clinical Practice

Adult intussusception: a continuously unveiling clinical complex illustrating both acute (emergency) and chronic disease management

PA Ongom*, SC Kijjambu
 

Authors affiliations

(1) Department of Surgery, School of Medicine, Makerere College of Health Sciences, Makerere University, Kampala, Uganda

* Corresponding author E-mail: petongom@yahoo.co.uk

Abstract

Introduction

Adult intussusception is a rare cause of intestinal obstruction. Its occurrence often presents clinicians with a diagnostic conundrum owing to its broad variation in clinical presentation. Over the last half century, studies have continuously contributed to the better understanding of the aetiology, diagnosis and treatment. The aim of this review is to discuss acute and chronic disease management in adult intussusception.

Discussion

The aetiology has multiple dimensions to its description. These include its location in the gastrointestinal tract, presence or absence of a physical or functional initiating lesion (lead point) and the behavioural characteristics of this lead point, be it benign or malignant. The symptoms and signs of intussusception are wide ranging, making it have a presentation anywhere between an acute and a chronic intestinal obstruction. Radiological investigations for diagnosis can be quite accurate in the hands of skilled and experienced radiologists. The hallmark of treatment is open or laparoscopic (operative) surgery.

Conclusion

This clinical entity calls for a high index of suspicion coupled with relevant radiological investigations in its diagnosis. We are observing a trend in which unique aetiologies are being unveiled to add to an eve-growing list. Even with the standard treatment being essentially surgical, there is an increasing trend towards the use of novel surgical methods such as advanced colonoscopic and laparoscopic techniques. All these factors have prompted us to generate a critical review of the literature on adult intussusception so as to give a better holistic picture of the essential critical clinical care.

INTRODUCTION

Adult intussusception is a rare disease. The lower age limit for ‘adults’ has never been conventionally fixed. Most institutions lean towards 12 years of age. Its clinical features, diagnosis and treatment bring out a lot of debate among clinicians. It has a presentation ranging from the classical to the atypical forms. The first clinical case of intussusception was reported in 1674 by Barbette of Amsterdam. John Hunter documented its description in 1789[1], known as ‘intosusception’ at the time. Almost a century later, the first successful operation was performed on a child by Sir Jonathan Hutchinson[2].

Adult intussusception constitutes less than 5% of intussusception cases[3,4]. Its incidence in resource-rich countries is 2–3 per 1,000,000 of the population per year[5]. There is a male to female ratio of 1.8:1[5]. This ratio is debatable as some studies show female dominance[6,7]. More recent reviews have paid less attention to the sex ratio[3]. It is the cause of 1%–3% of all cases of intestinal obstructions[5,8], although a contrasting African series ranked it as the fourth leading cause[9], and accounts for less than 1% of hospital admissions[10]. There is a demonstrable cause in the majority of cases, usually an intraluminal neoplasm. Prominent reviews point to a 70%–90% existence of an underlying pathological cause[4,5,8,11,12]. These are mainly polyps and colonic malignancies. In contrast, childhood intussusception is a leading cause of intestinal obstruction. The treatment of the condition has always had some controversy. However, most authorities over the years have tended to agree on one common point—the treatment is surgical. This review discusses how to manage acute and chronic diseases in adult intussusception.

DISCUSSION

The authors have referenced some of their own studies in this review. These referenced studies have been conducted in accordance with the Declaration of Helsinki (1964) and the protocols of these studies have been approved by the relevant ethics committees related to the institution in which they were performed. All human subjects, in these referenced studies, gave informed consent to participate in these studies.

Pathophysiology

Intussusception is defined as the telescoping or invagination of one segment of gut into another. This is predominantly in a proximal to distal direction, the natural physiological peristaltic process. The mechanism for initiation of the invagination is not clear. It is postulated that any lesion in the bowel wall or an irritant within its lumen may alter the normal peristaltic pattern and can trigger an invagination eventually leading to intussusception[13]. The portion of the gut propelled distally is known as the intussusceptum, with the distal (receiving) portion being the intussuscepiens (Figure 1).

Schematic diagram illustrating the structure of an intussusception. Longitudinal (top) and cross-sectional (bottom) diagrams illustrate a typical intussusception, with invagination of a segment of the gastrointestinal tract, intussusceptum (solid arrows), into an adjacent segment, intussuscepiens (open arrows). The mesentery (M) and mesenteric vessels (arrowheads) follow the gut invagination.

Concerning the aetiology, intussusception may be viewed in two contexts: a primary type and a secondary type. Intussusceptions with no clear lead point are the primary or idiopathic type, present in 8%–20% of cases, and more likely to occur in the small intestines[5,14,15]. In contrast, the secondary type, constituting the greater majority, is due to an existing gut pathological lesion. This lesion is best described as a lead point: a functional or structural lesion associated with the intussusceptum[16], postulated to be the ‘trigger’ for intussusception[14,17]. The commonest ‘lead points’ are colonic malignant tumours, in up to 60% of the cases[5]. Benign tumours constitute the majority of the remaining 40%.

Following the initiation of invagination, there is progressive propulsion of the intussusceptum, with or without the lead point, in rhythm with the peristaltic wave of the gastrointestinal tract. The intussusceptum carries along its mesentery. Due to the compromised space within the intussuscepiens, there is obstruction of the lumen of both the intussusceptum and intussuscepiens (Figure 2a). Accompanying this is the compromise of the mesenteric vascular flow to the intussusceptum: lymphatic, venous and arterial obstruction, in that order. The result is bowel obstruction and inflammatory changes: oedema, thickening and ischaemia of the bowel wall. Continued peristalsis will offset a vicious cycle of more oedema, obstruction and ischaemia, with subsequent accentuation of each of these with time. Gangrene may result (Figure 2b). Contemporaneously with all these happenings are the classical pathophysiological manifestations of intestinal obstruction: proximal distension, anatomical distortion, distal collapse and altered absorption and secretion.

(a) Ileocolic intussusception following resection without reduction. A typical finding at exploratory laparotomy for intussusception. The RED arrow is the ileum, while the BLUE arrow is the point of invagination; intususceptum–ileum, and the proximal part of the intussuscepiens (also ileum). The YELLOW arrow illustrates the ascending colon; distal end of intussuscepiens. (b) Ileocolic intussusception with strangulation. The intususcepiens (ascending colon) is opened to reveal the intussusceptum constituted of ileum that has undergone ischaemia and necrosis; strangulation. Haemorrhagic and dark areas indicate necrosis and the onset of gangrene

Location

The most common sites for intussusception are the junctions between freely moving segments and fixed (retroperitoneally or adhesionally) segments[18], a mechanism favouring invagination. Intussusceptions have been classified according to their locations into four categories: (1) entero-enteric—involving the small intestines; (2) colo-colic—involving the large intestines; (3) ileo-colic—invagination of the terminal ileum into the ascending colon and (iv) ileo-caecal—the ileo-caecal valve being the lead point of the intussusceptum. The distinction between the ileo-colic and ileo-caecal forms is challenging[12,13]. Two other categories may be included for clarity, though they are part of the colo-colic entity: (1) colo-rectal—colon invaginates through rectal ampulla and (2) recto-rectal—with rectum invaginating into the rectum but with no anal protrusion. Although there are cases of gastric involvement, this classification does not cover them.

Aetiology

These can be benign, malignant or idiopathic causes. The aetiology also offers another form of classification and description of intussusceptions. A small intestinal intussusception is secondary either to the presence of luminal/intra-luminal or extra-luminal lesions (lead points). There are numerous specific lesions. The following have all been observed: inflammatory lesions, Meckel’s diverticula, postoperative adhesions, lipomas, adenomatous polyps, lymphomas, neurofibromas and scleroderma. Reported iatrogenic causes have involved intestinal tubes[19] and a patient with gastrojejunostomy[20]. For large intestines, benign tumours are more often adenomas, the most frequently occurring type (up to 26%)[21], and lipomas.

Malignancy accounts for up to 30% of cases of intussusception occurring in the small intestines[14]. The specific types encountered are adenocarcinoma, melanoma, lymphoma, sarcomas and squamous cell carcinoma[3]. On the other hand, from 60%[6] to 65% of cases[12,22] of intussusception occurring in the large bowel are more likely to have a malignant aetiology. One review differed by having 67% of all cases, the majority, being secondary to benign conditions[23]. However, this was a rather short 3-year review.

The more frequently reported types are adenocarcinoma, melanoma and lymphoma. Gastrointestinal stromal tumours (GISTs) have been reported in both small and large intestines. They were previously confused with leiomyomas, leiomyosarcomas and other mesenchymal tumours of the gut. This clinical entity is being increasingly recognised since the advent of its definition over a decade ago as specific tyrosine-protein kinase (KIT)-expressing mesenchymal tumours[24]. After the year 2000, there has been a marked rise in case reports of GISTs, a trend not seen in the past. Novel laboratory diagnostic techniques may account for their increased identification. Reported cases between 2009 and 2012 are listed in Table 1.

Table 1

Reported cases of gastrointestinal stromal tumours (GISTs) as causes of intussusception between 2009 and 2012.

There has never been a uniform perspective of classification of the aetiological factors involved in intussusception. Study reviews conducted during the last 4 decades of the twentieth century tended to be centre-oriented and gave details of the specific aetiology for each case of intussusception. These reviews generally covered periods of one to two decades. Even with the relatively small number of cases, differing institutions show a wide range in variation of specifics[4,5,11,12]. However, there are some uniform trends seen in most reviews. More recent reviews tend to offer a mixed picture, some give detail[7], including comprehensive description[11], while others have focused less on the percentages of particular aetiologies, taking into account the wide variation in differential diagnoses[3]. There is little wonder, therefore, that there is arguably more recent literature in the form of case reports and case reviews. Table 2 presents a summary of some of the specific aetiologies for three selected review studies.

Table 2

Aetiological lesions causing adult intussusception from three selected review studies spanning three decades

Clinical presentation

The clinical presentation of adult intussusception varies considerably. The presenting symptoms are often non-specific and the majority of cases have been reported as chronic, consistent with partial obstruction[5,25]. The classic triad of crampy abdominal pain, bloody (‘currant jelly’) stool and a palpable mass of acute intussusception in paediatric presentation is rare. The predominant symptoms are those associated with some form of bowel obstruction and most times still described non-specifically. These are abdominal pain and distension, nausea, vomiting, gastrointestinal bleeding, constipation and changes in bowel habits[12,13]. Three-quarters of patients (78%)[5] present with abdominal pain, nausea and vomiting. Pain is the commonest symptom, present in 90% of the patients[7]. Nausea and vomiting come next in line, though with varying frequencies. Fever, weight loss, constipation and diarrhoea are infrequent. A palpable abdominal mass is present in less than 10% of the patients. Bloody stool is seen only in one-quarter of the patients[5]. Dance’s sign (apparent right iliac fossa ‘emptiness’) is only occasionally appreciable. Overall, the symptoms and signs of acute intestinal obstruction are present only in one-half of the patients. The other half presents with chronic symptoms (non-emergencies) over a period from weeks to months.

The clinical features also have an association with the underlying pathological lesion’s nature and site, and the presence or absence of a lead point. A transient non-obstructing intussusception without a lead point is frequently idiopathic and, in the past, has been described as occasionally spontaneously resolving without any specific treatment. Contrastingly, intussusception with an organic lesion as the lead point usually presents as a bowel obstruction, acute, persistent or relapsing. Patients with benign enteric lesions have been said to have a higher frequency of nausea, vomiting and abdominal pain. Those with colonic malignancies tend to present more with bloody or melaena stools[5]. This may plausibly be explained by the pathophysiological disruption due to location and character of the tumour type. The mean duration of symptoms appears not to be of clinically practicable value, considering the variation in symptomatology. The symptom duration range has been reported to be between 1 and 365 days, or even longer. The mean duration of symptoms is commonly observed as being longer in benign as compared with malignant lesions, and in enteric as compared with colonic lesions. Pinpoint details of means, medians and modes for benign enteric versus colonic and malignant enteric versus colonic are not covered by previous reviews.

INVESTIGATIONS FOR DIAGNOSIS

Imaging

Adult intussusception is one of those conditions that may be difficult to diagnose with a good degree of confidence based on the clinical features alone. Moreover, there is variation in the imaging characteristics too. Matching the clinical presentation and imaging characteristics to make a preoperative diagnosis is challenging. Accurate preoperative diagnoses have been reported at rates as low as 40.7%[6] and 50%[26]. Plain abdominal films are commonly the first investigation, considering that obstructive symptoms dominate the clinical picture in most patients. The common signs of intestinal obstruction are usually demonstrated, providing information regarding the site of obstruction[7,27]:multiple air fluid levels and a ‘questionable’ mass[7]. Upper gastrointestinal contrast series (Table 3) may show a ‘stacked coin’ (Figure 3a) or ‘coil-spring’ (Figure 3b) sign, while a barium enema examination, useful in colo-colic or ileo-colic intussusception, may show a ‘cup-shaped’ filling defect, or ‘spiral’ or ‘coil-spring’ signs[6,7].

Table 3

Radiological signs of intussusception

Contrast radiological appearance of intussuscepted intestines. (a) This demonstrates the ‘Stacked coin’ sign. (b) This demonstrates the ‘Coiled spring’ sign.

Ultrasonography is a useful investigation for the diagnosis of intussusception, both in children and in adults[28,29]. In many centres, it is the standard investigation. The classical imaging features (Table 3) include the ‘target’ (Figure 4a) or ‘doughnut’ signs in the transverse view, and the ‘pseudo-kidney’ (Figure 4b) sign or ‘hay-fork’ sign in the longitudinal view[29]. This procedure and its interpretation require good operator knowledge and skill. However, obesity and the presence of large amounts of air in the distended bowel loops limit the image quality and the subsequent diagnostic accuracy.

Ultrasonographic appearance of intussuscepted intestine. (a) This illustrates the classic ‘Target’ or ‘Doughnut’ sign; transverse view. (b) This illustrates the ‘Pseudo-Kidney/ sign; longitudinal view.

Abdominal computed tomography (CT) is currently considered as the most sensitive radiological method to confirm intussusception, with a reported diagnostic accuracy ranging from 58% to 100%[5,30]. The characteristic features include a heterogeneous ‘target’ (Figure 5a) or ‘sausage-shaped’ (Figure 5b) soft-tissue mass with a layering effect (Figure 5c; Table 4). Mesenteric vessels within the bowel lumen are also typical[13]. A CT scan may define the location and nature of the mass, its relationship to surrounding tissues and may contribute to staging of a tumour for a suspected malignant cause[7]. It facilitates distinguishing between intussusception without a lead point from that with a lead point[31]. In most cases, radiologists can readily make the correct diagnosis. However, it is broadly agreed that these CT findings that help differentiate between lead point and non-lead point intussusception have a considerable degree of overlap[32]. It is accepted that when a lead mass is seen at CT as a separate and distinct entity in contrast to oedematous bowel, it can be considered a reliable indicator of a lead point intussusception. Differentiating between lead point and non-lead point intussusception is important in determining the appropriate treatment and has the potential to reduce the prevalence of unnecessary surgical interventions.

Table 4

CT features distinguishing between lead point and non-lead point intussusception

Contrast–enhanced CT scan of the abdomen showing intussusception of small intestines. Illustrated are classic ‘Target’ sign (arrow in a), and the ‘Sausage-shaped’ mass (arrow in b) mass. These signs are considered pathognomonic for intussusception. (c) Contrast-enhanced CT scan of the abdomen showing small gut intussusception. Illustrated is the typical multilayered appearance of an intussusception. The intussusceptum (black arrowhead), with accompanying mesenteric fat and blood vessels (arrow), is surrounded by the thick-walled intussuscepiens (white arrowhead).

Decision-making using radiological findings remains a balancing act[32]. In a study with 15 patients, 7 Patients were operated on with diagnoses of intussusception based on imaging findings. The remaining eight patients had their diagnoses made at operation. Different imaging modalities were used[32]. Zubaidi et al. reported an even lower preoperative diagnosis frequency of 14%[7]. Specifics of the imaging modalities were not available.

Endoscopic diagnosis

Flexible endoscopy of the lower gastrointestinal tract is very valuable in evaluating the cases of intussusception presenting with subacute or chronic large bowel obstruction[14]. Its main benefits are confirmation of the intussusception (Figure 6), its localisation, demonstration of the underlying organic lesion serving as a lead point and possible treatment. Snare polypectomy has been used to treat polypoid causes, though it is considered unsafe for chronic intussusception considering the background of chronic tissue ischaemia and possible necrosis of the intussuscepted bowel segment’s wall[33]. However, it has limited use for large lead points such as ‘giant’ lipomas[34]. Lipomas offer characteristic colonoscopic features (Table 5). Colonoscopy has been successfully used to reduce intussusception[35].

Table 5

Colonoscopic features of lipomas, frequent colonic intussusception lead points

Colonoscopic view of intussusception. Illustrated are the intussusceptum (blue arrow) and intussuscepiens (yellow arrow).

TREATMENT:

Because adults present with acute, subacute or chronic non-specific symptoms[22], the initial diagnosis is often missed or delayed and is then established at surgery (Figure 7). Most surgeons agree that adult intussusception requires surgical intervention because of the large proportion of structural anomalies and the high incidence of malignancies. However, the extent of bowel resection and manipulation of the intussuscepted bowel during reduction remains controversial[14]. In contrast to paediatric patients, preoperative reduction with barium or air is not a definite treatment for adult intussusception[6,14], except a few adolescent cases. There are potential risks associated with preliminary manipulation and reduction of an intussusception; (1) intraluminal tumour seeding, (2) venous tumour dissemination, (3) gut perforation with peritoneal seeding of microbes and tumour cells and (4) increased risk of anastomotic complications of the friable and oedematous bowel, in case of resection and anastomosis[7,8,13,14,26]. Some authors argue that reduction should not be attempted if there are signs of inflammation or ischaemia of the bowel wall[30].

Ileocolic intussusception found at laparotomy. The yellow arrow points to ileum at the point of invagination into the caecum/ascending colon and the red arrow points to the intussuscepiens containing intussusceptum. The green arrow illustrates mesentery. Deep blue arrow points to an enlarged lymph node within the mesentery.

Therefore, in patients with ileo-colic, ileo-caecal and colo-colic intussusceptions, especially those over 60 years of age, formal resections (open or laparoscopic) using appropriate oncological principles are recommended as there is a high incidence of malignancy as the underlying aetiology. Primary anastomosis between healthy and viable tissue is done[6,12,14,26]. For right-sided colonic intussusceptions, resection and primary anastomosis can be carried out even in unprepared bowel[5], while for left-sided or rectosigmoid cases resection with construction of a colostomy or a Hartmann’s procedure, and secondary anastomosis is recommended especially in the emergency setting. However, when a preoperative diagnosis of a benign lesion is safely established, the surgeon may reduce the intussusception by milking it out in a distal to proximal direction[36], allowing for a limited resection. Often, chronic intussusception does not allow for successful manual reduction to be performed, due to thickening, fibrosis and cross-scarring within the intussusceptum[36] (Figure 8).

Chronic ileo-caeco-colic intussusception; the affected gut has been resected. Green arrow – lead point of the intussusceptum. Yellow arrow – ischaemic changes over the intussusceptum. Red arrow – haemorrhagic areas. The intussusceptum was only partially reducible. Histology showed chronic fibrosis and ischaemic changes, but no gangrene. This intussusceptum had protruded per anus. There was no tumour.

Enteric intussusceptions due to benign lesions require only reduction and limited resection[37]. Reduction alone is adequate for idiopathic forms provided the bowel appears non-ischaemic and viable[5]. Some patients at risk of a short bowel syndrome require special consideration. Two typical scenarios demonstrate this:

Multiple small intestinal polyps causing intussusception, as in Peutz-Jeghers syndrome—a combined approach of limited intestinal resections and multiple snare polypectomies should be done[38].

Intussusception involving almost the entire colon and significant ileal length—‘milking’ a substantial length, then resection of what is irreducible[36].

Several reports have described the laparoscopic approach to treatment of adult intussusception for various lesions of both small and large bowel (Table 6). It has been used successfully in selected cases, depending on the general status of the patients and sufficient laparoscopic expertise of the surgeon. Laparoscopic-assisted surgery is also used in suitable cases[39]. This involves laparoscopic exploration first for diagnosis (Figure 9), followed by an easier definite resection procedure[39].

Table 6

Documented laparoscopic and laparoscopically assisted surgeries for intussusception done in recent years. Each case experience is particularly unique

Laparoscopic view if small intestinal intussusception. Illustrated is a typical invagination of an intussusceptum into an intussuscepiens.

There is ongoing debate on when to use endoscopy or laparoscopy, especially for lipoma lead points. Many surgeons manage patients with small asymptomatic colonic lipomas with regular follow up. For those that are large (diameter >2 cm) and/or symptomatic, resection is considered, although the choice between endoscopic or surgical resection (open or laparoscopic) remains debatable. Lipomas even >2 cm have been safely removed by endoscopic resection. When surgery is indicated, the practice is tending towards laparoscopy as the ideal approach in all patients for whom minimally invasive surgery is not contraindicated[40]. Favourable outcomes have also been noted with adenomas.

CONCLUSION

Intussusception in adults is an infrequent problem. Nevertheless, it is a challenging condition that requires the surgeon to understand its epidemiology, anomalous clinical presentation and treatment options. Diagnosis can be puzzling because of non-specific and often subacute symptoms with no out right pathognomonic clinical signs.

A strong pillar towards correct management is having a high index of suspicion. The continuously increasing variety of possible aetiological lesions, evidenced by the high case report numbers, means we can never be sure of the pathology for the next case till after surgery. There is no ‘gold standard’ diagnostic test and many cases are diagnosed at laparotomy.

Treatment usually requires resection of the involved bowel segment. Reduction can be attempted in small-bowel intussusception if the segment involved is viable or malignancy is not suspected. A more careful approach is recommended in colonic intussusception because of a significantly higher chance of malignancy. This entire critical review process has enabled us to propose a diagnostic and treatment guiding algorithm (Figure 10).

Basic algorithm for diagnosis and treatment of adult intussusception.

Abbreviations list

CT, computed tomography; GIST, gastrointestinal stromal tumour.

Authors contribution

All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.

Competing interests

None declared.

Conflict of interests

None declared.

A.M.E

All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.

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Reported cases of gastrointestinal stromal tumours (GISTs) as causes of intussusception between 2009 and 2012.

Author (year) Case of GIST
Wilson et al. (2012) GIST presenting as gastroduodenal intussusception.
Basir et al. (2012) Gastroduodenal intussusception as a first manifestation of a gastric GIST
Seok et al. (2012) Gastroduodenal intussusception due to pedunculated polypoid GIST
Akbulut et al. (2012) Ileocolic intussusception due to a GIST
Gyedu et al. (2011) GIST presenting acutely as gastroduodenal intussusception
Gupta et al. (2011) GIST causing ileo-ileal intussusception
Andrei et al. (2011) Intestinal intussusception due to ileal GIST
Wall et al. (2010) GIST presenting with duodenal-jejunal intussusception
Pirscoveanu et al (2010) GIST in the caecum causing ileo-caecal-colic invagination
Menendez-Sanchez et al. (2009) Gastrointestinal bleeding and intussusception due to GIST
Matek et al. (2009) GIST as a cause of the small intestine invagination
Theodoropoulos et al. (2009) GIST causing small bowel intussusception in a patient with Crohn's disease www.ncbi.nlm.nih.gov/pubmed/19891025
Chan et al. (2009) Endo-laparoscopic reduction and resection of gastroduodenal intussuception of a GIST

Aetiological lesions causing adult intussusception from three selected review studies spanning three decades

Aetiology Nagorney (1980) Azar (1997) Zubaidi (2006)
Small gut (%) Large gut (%) Small gut (%) Large gut (%) Entire gut (%)
Benign
Adhesions (postoperative) 25 6
Idiopathic 29.2 2.3 13.6
Lipoma 12.5 6.8 21.4 9.1
Meckel's diverticulum 12.5 6.8 4.5
Adenoma 33.3 14.3
Leiomyoma 4.5
Lymphohyperplasia 7.1
Ruptured aneurysm 4.5
Neurofibroma 2.3
Scleroderma 2.3
Peutz-Jegher's syndrome 8.3 4.6
Malignant
Adenocarcinoma 58.3 2.3 42.3 18.2
Leiomyosarcoma 8.3 4.2 4.5
Melanoma 8.3 29.5 9.1
Lymphoma 6.8 4.5
Metastases 12.5 9.1

Radiological signs of intussusception

Upper gastrointestinal contrast radiography:

Stacked-coin sign

Coil-spring sign

Lower intestinal contrast (barium) radiography:

Cup-shaped defect

Spiral sign

Coil-spring sign

Ultrasonography:

Transverse view—‘target’ or ‘doughnut’ sign; ‘'crescent-in-a-doughnut sign

Longitudinal view—‘ pseudo-kidney’ or ‘hay-fork’ sign

Computerised tomography:

‘Target’ sign

‘Sausage-shaped’ sign

CT features distinguishing between lead point and non-lead point intussusception

Lead point intussusception

Signs of bowel obstruction

Bowel wall oedema

Loss of the classic three-layer appearance

Demonstration of the lead mass

Non-lead point intussusception

No signs of proximal bowel obstruction

Target-like mass · Sausage-shaped mass

Layering effect

Colonoscopic features of lipomas, frequent colonic intussusception lead points

Feature Manoeuvre eliciting feature
Smooth surface Regular and continuous on observation
‘Cushion sign’ or ‘Pillow sign’ Exertion of pressure with forceps against the lesion results in depression of the mass
‘Naked fat sign’ Extrusion of fat while performing a biopsy

Documented laparoscopic and laparoscopically assisted surgeries for intussusception done in recent years. Each case experience is particularly unique

Author (Year) Procedure
Son et al. (2013) Laparoscopic surgery for an intussusception caused by a lipoma in the ascending colon.
Rose et al. (2012) Laparoscopic longitudinal jejunectomy for intussusception after gastric bypass.
Kim et al. (2012) Laparoscopic colectomy of colonic intussusceptions in adults
Basterra et al. (2011) Laparoscopic management for giant lipoma-induced colonic intussusception.
Lucas et al.(2010) Laparoscopic resection of a small bowel lipoma with incidental intussusception.
Ho et al. (2010) Post-colonoscopy colonic intussusception reduced via a laparoscopic approach.
Greenley et al. (2010) Laparoscopic management of sigmoidorectal intussusception.
Harvey et al. (2010) Laparoscopic resection of metastatic mucosal melanoma causing jejunal intussusception.
Lin et al. (2007) Laparoscopy-assisted resection of ileoileal intussusception caused by intestinal lipoma.
Palanivelu et al. (2007) Minimal access surgery for adult intussusception with subacute intestinal obstruction: a single centre's decade long experience.
Chuang et al. (2007) Laparoscopic management of sigmoid colon intussusception caused by a malignant tumor
Ishibashi et al. (2007) Laparoscopic resection for malignant lymphoma of the ileum causing ileocecal intussusception.
Akatsu et al. (2007) Adult colonic intussusception caused by caecum adenoma: successful treatment by emergency laparoscopy
McKay et al. (2006) Ileocecal intussusception in an adult: the laparoscopic approach
Wu et al. (2006) Laparoscopic diagnosis and treatment of small bowel obstruction caused by postoperative intussusception
Park et al. (2006) Sigmoidorectal intussusception of sigmoid colon adenoma treated by laparoscopic anterior resection after sponge-on-the-stick-assisted manual reduction
Jelenc et al. (2005) Laparoscopically assisted resection of an ascending colon lipoma causing intermittent intussusception.
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