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Intussusception in adults
Intussusception DUDLEY
in Adults
M.D. AND RICHARDW. ZOLLINGER, M.D., Columbus, Obio
F. BRIGGS, M.D., JOHN CARPATHIOS,
From tbe Department Columbus, Obio.
ofSurgery,Mount
Carmel Hospital,
type. In the iIeocecaI intussusception, the head of the cecum forms the head of the intussusceptum. As pointed out by Brayton and Norris [2] it is important to differentiate, in aduIts, between the iIeoceca1 and the iIeocoIic types since the causative Iesion in ileocolic intussusception is enteric and statisticaIIy much Iess IikeIy to be mahgnant than the iIeoceca1 type in which the Iesion originates from the cecum.
of the intestine is rare in aduhs. Therefore, the surgeon must reIy on the compilation of severa isoIated case reports if he is to attain some knowledge of the frequency of occurrence and the unusual features of the disease. During the years 1954 to 1959, there were 83,661 adult admissions to Mount CarmeI Hospital in Columbus, Ohio. There were four cases of adult intussusception in this group. We have reviewed three of them. The incidence we have found is simiIar to that reported by Donhauser and KeIIy [a]. Among the 242,829 patients admitted at the AIbany Hospital in New York during the years 1927 to 1947, there were twelve cases of intussusception in patients who were fifteen years of age or order.
I
NTUSSUSCEPTION
LOCATION
AND OCCURRENCE
Intussusception may occur anywhere in the gastrointestina1 tract beIow the gastric cardia. The reIative frequency of occurrence of intussusception at the various sites in 748 cases (four of which were muItipIe) is shown in Figure 2. This incIudes 665 cases reported by Donhauser and KelIy [4], 80 cases reported by Brayton and Norris [2], and the 3 cases reported herein. Gastrogastric and gastroduodenal intussusceptions represented 6 per cent of this series, enteric 40 per cent, iIeocoIic I3 per cent, iIeoceca1 16 per cent, appendicoceca1 4 per cent, coIocoIic 17 per cent and stoma1 4 per cent.
CLASSIFICATION Intussusception may be described as the invagination of a segment of the gastrointestina1 tract into an adjacent portion. The proxima1 segment usually invaginates into a dista1 portion; however, a retrograde type occasionaIIy may occur. An intussusception is primary (idiopathic) if no initiating pathology is found and secondary if an expIanatory lesion is discIosed. A compound intussusception is one in which there are more than the usua1 three cyIinders of a simpIe intussusception. Stoma1 intussusceptions occur as a comphcation of previous operative procedures such as gastrojejunostomy, coIostomy and ileostomy. The different types of intussusception can be divided into two main groups-enteric and cohc. These can be subdivided into four subtypes. (Fig. I.) They are iIeocoIic, iIeoceca1, colic and enteric. IIeocoIic is considered to be of the enteric type, while iIeoceca1 is of the colic
ENTERIC
FIG. I. Types of intussusception in ad&s. I09
American
Journal of Surgery,
Volume IOI. January
1961
Briggs,
Carpathios
and ZoIIinger TABLE I SITES
OF
RESPONSIBLE
MALIGNANT FOR
AND
BENIGN
Maiignant
TUMORS
(413
INTUSSUSCEPTION
Benign
CASES)
*
Caused by Tumor
Site
ILEOCOUC 13%
(No.)
ENTERIC 40 %
(%o)
____ APPENDICOCECAL40/eJ
FIG. 2. Sites of intussusception
(No.1
(%)
(No.1
(%o)
~--__
STOMAL 4 %
Gastric, duodenal. Enteric . Colic Total.
in adults.
ETIOLOGY
Of a11 intussusceptions, 5 to 7 per cent occur in aduIts [3,7,8,11]. The intussusceptions that occur in infants and chiIdren are predominateIy primary with no demonstrabIe cause (go to g5 per cent). In adults 80 per cent or more of the cases of intussusceptions are of a secondary nature, because they have a demonstrabIe cause. The causes of intussusception in the aduIt are many and varied. However, the vast majority (approximately 55 per cent) are initiated by tumors. The etioIogic factors in order of decreasing incidence are: benign tumors, malignant tumors, primary (idiopathic), Meckel’s diverticuIum, stomal, prolapse of gastric mucosa, chronic ulcerations in typhoid fever and tubercuIosis, .adhesions, aberrant pancreas [I], trauma, foreign body (incIuding Miller-Abbott tube), and miscellaneous (incIuding viscera1 purpura and mobile cecum). As previously stated, approximateIy 55 per cent of all intussusceptions are caused by tumors. It is aIso true that tumors are the etiologic factor in 6 per cent of the intussusceptions invoIving the gastroduodena1 segment, 54 per cent of the enteric area and in 40 per cent of those affecting the colon. (Table I.) The incidence of malignancy of tumors in these regions was 15 per cent for the gastroduodena1 segment, 28 per cent for the small bowel portion, and in 64 per cent of those in the colonic areas. The mechanism invoIved in the production of an intussusception of the idiopathic or primary type is postuIated as being a proximal wave of contraction adjacent to a distal segment of relaxation. In a secondary intussusception a lesion apparently is responsible for starting an invagination by acting as a focus of stimulation of muscular contraction causing an
. .
3 62
I5 28
IO7 ‘72
64 4I
18
85
6
21
I63 60 241
72 36 59
54 40 413
225 I67 100
* Modified from Roper [IO].
increased peristaIsis of the intestine and, thus, teIescoping invagination of one segment into an adjacent portion. The Iumen of the invaginated bowel (intussusceptum) is narrowed but rareIy compIeteIy obstructed [12]. The mesentery and wa1Is of the intussusceptum become compressed and edematous and further aggravation of the degree of obstruction ensues. Acute intussusceptions rapidly tend to become irreducibIe due to these changes and ulceration, and gangrene and perforation of the intussusception may occur. CASE
REPORTS
CASE I. F. W., a forty-eight year old pharmacist, was admitted to Mount Carmel Hospital on JuIy zg, 1959. Approximately eight hours previously he experienced acute onset of severe periumbilical pain which was accompanied by nausea, vomiting and moderate abdominal distention. His symptoms persisted and were progressive at the time of admission. Similar episodes of abdominal pain with nausea and vomiting which terminated spontaneously and were less severe had occurred in February and again in June of 1959. There had been no hematemesis or melena. He had been given antacids and antispasmodics for peptic uIcer, which had not been documented by prior X-ray examination. He had undergone no previous surgery. On admission there was Iocalized distention of the left upper quadrant with tenderness over the area of distention and rebound tenderness. The abdomen was soft in the other quadrants and there was no guarding. Bowel sounds were absent except for high-pitched sounds over the area of distention. Supine and upright X-ray films of the abdomen disclosed dilatation of small bowe1 loops in the upper abdomen. The chest fiIm was not remarkable. 110
Intussusception
in AduIts with 5 per cent nonsegmented neutrophiIs, 4g per cent segmented neutrophiIs, 45 per cent Iymphocytes and I per cent monocytes. The serum amylase was 136 Somogyi units. The admitting diagnosis was perforated duodena1 ulcer. ApproximateIy eight hours folIowing the onset of his symptoms, an exploratory abdomina1 Iaparotomy was performed through a right upper rectus incision. There was no free air in the peritonea1 cavity, and the stomach and duodenum appeared normal. The smaI1 bowe1 was explored and in the Ieft lower quadrant there was a dilated, firm Ioop which revealed an enteric intussusception of the proximal ileum when it was delivered from the abdomen. The circuIation of the invoIved bowel was not seriously compromised and the intussusception which involved approximately eighteen inches of jejunum and proximal ileum was reduced. An intraluminal poIyp (3 cm.) was found to be Ieading the intussusception. The polyp was resected in its entirety through a IongitudinaI enterotomy. The tumor appeared to be benign. However, a diagnosis of infiltrating mutinous adenocarcinoma was made from permanent microscopic sections. Much of the mass forming the polyp was actuaIIy tumor invading serosal fat. The patient passed bright red bIood per rectum on his first three postoperative days. His hemogIobin feI1 to 6.6 gm. per cent and he was transfused with 1,500 cc. of whoIe blood. The bIeeding ceased and the patient did well. On December I 7, I 956, an upper gastrointestina1 series was obtained to ruIe out the presence of further polyps of large or smaI1 bowe1. None was found; however, the suggestion of a duodena1 uIcer was seen. The patient was discharged on December 19, 1956 without further compIication. He was readmitted on January 13, 1957 and underwent a segmenta resection of the iIeum at the site of the previous enterotomy. No evidence of maIignancy was found in the specimen. An end to end anastomosis was performed. The patient did we11 and was discharged on his tenth postoperative day.
Admission Iaboratory tests reveaIed that the hemoglobin was 14 gm. per cent, hematocrit was 43 per cent, the leukocyte count was I 1,200 per cu. mm. with z per cent nonsegmented neutrophils, 82 per cent segmented neutrophiIs, and 16 per cent Iymphocytes. The serum amyIase, serum electrolytes, prothrombin time, bIood urea nitrogen and urinalysis were within norma Iimits. : ,The admission diagnosis was mechanica obstruction of the smaI1 bowel. An expIoratory abdominal Iaparotomy was performed tweIve hours after admission. The abdomen was opened through a right paramedian rectus incision immediateIy reveaIing a greatIy diIated Ioop of smal1 bower approximateIy fourteen inches in Iength which was approximately three feet proxima1 to the iIeoceca1 valve. An enteric intussusception was found and reduced manually. FolIowing reduction, it was found that the leading point of the intussusception was a mass extending from the serosa of the bowe1 which was continuous with a poIypoid intraluminal mass. There was no compromise of the circulation. However, the mesentery was Iigated segmentally. The bowel was transected proximal and distal to the tumor which was removed with the ileum anastomosed end to end. Microscopic examination reveaIed a bizarre, IocaIIy invasive, non-epitheIia1 type of tumor of the intestina1 waI1, probabIy arising from muscIe. It was not encapsuIated and the overIying mucosa was uIcerated. The patient did we11 postoperativeIy and was discharged on his seventh postoperative day. CASEII. J. M., a thirty year old insurance agent, was admitted to Mount CarmeI Hospital on December 7, 1956, approximateIy three hours foIIowing the acute onset of upper abdomina1 pain. The patient had a history of proven peptic uIcer in 1947 which was treated medicaIly with the cessation of symptoms. He had enjoyed good health from 1947 unti1 the day of admission when his chief compIaint was an epigastric, coIicky pain, accompanied by nausea, vomiting and Iassitude. He had a norma bowel movement the day of admission. The patient had had an appendectomy in the remote past. On admission, the patient had a rigid abdomen with severe upper abdominal pain and tenderness in the Iower abdomen as weI1, more marked in the right Iower abdominal quadrant. No masses were paIpabIe in the abdomen. The bowe1 sounds were hypoactive. Rdentgenograms of the chest as we11 as upright and supine fiIms of the abdomen revealed no abnormaIity. Admission Iaboratory work reveaIed that the hemoglobin was I I .7 gm. per cent, hematocrit was 40 per cent, and the leukocyte count was 17,000
CASE III. L. K., a seventy-one year oId man, entered Mount CarmeI Hospital on June 3, 1958 with a three week history of coIicky, Iower abdominaI pain with associated diarrhea and occasiona1 bright red streaking in his stoo1. There had been a few episodes of nausea with vomiting and a weight Ioss of ten pounds during the same period. On admission the patient’s abdomen was slightIy distended and tympanitic, but the bowe1 sounds were reportedty normal. There was some guarding and tenderness in the lower abdomen with a tendency to IocaIization in the right Iower quadrant. No abdominal mass was paIpabIe. Barium enema examination showed obstruction III
Briggs, Carpathios
and ZoIIinger
FIG. 4. The resected specimen (Case III). The transverse colon is opened over the leading point of the intussusception reveaIing the submucosa1
Iipoma.
surgica1 specimen was opened, revealing a submucosa1 Iipoma of the distal ileum which had Ied to the intussusception. (Fig. 4.) The patient recovered from the procedure without event and was discharged on his seventh postoperative day. DIAGNOSIS
FIG. 3. Barium enema (Case III) demonstrating a filling defect in the proxima1 transverse colon which represents the Iarge submucosal Iipoma. Note the typical “coiled spring” appearance.
The clinica diagnosis of intussusception is unfortunateIy seIdom suspected and so it is missed, due to the rarity of the condition in ad&s. The usua1 history is that of a chronic recurrent partial intestina1 obstruction. Intermittent abdomina1 coIicky pain is the most common symptom. Nausea, vomiting and obstipation enter into the clinica picture as the obstruction graduaIIy becomes compIete. Blood and mucous in the stoo1 occurs Iess often in aduIts than in infants [3,8]. In two of our three cases this symptom was absent. PaIpabIe abdomina1 tumor also is an unreIiabIe finding because it may or may not be present. This finding was absent in our three cases. A ffat fiIm of the abdomen may show evidence of bowe1 obstruction by demonstrating the diIated intestina1 loops. A barium enema may demonstrate the characteristic “coiIed spring” appearance in cases of iIeocolic or colocolic types of intussusception. This appearance is due to the passage of barium around the convex head of the intussusception with flow of barium between the foIds of the mucosa of the intussuscipiens:where it ensheaths the head of the intussusception. A mushroom or crescentic appearance may aIso be seen at the point of obstruction. These signs are usuaIIy of no vaIue in the “enteric” cases (iIeoiIea1, jejunoiIea1) of intussusception, since they are dependent en-
of the proximal transverse colon with the appearance of intussusception. (Fig. 3.) A poIyp of the distaI ileum had been demonstrated three weeks prior to hospitalization by prior barium enema. Therefore, the admitting diagnosis was iIeocoIic intussusception. On June 9, 1958 expIoratory surgery was performed through a right midrectus incision. A huge iIeocoIic intussusception was encountered invoIving iIeum, cecum and ascending coIon. Because of the inflammatory changes and the inabiIity to reduce the intussusception, a right hemicolectomy and iIeo-transverse colostomy was performed. The
FIG. 5. Operative reduction of intussusception
in aduIts. II2
Intussusception tireIy on refIux through the ileocecal valve into the terminal iIeum and only in rare instances does regurgitation of the barium enema through an incompetent ileocecal valve demonstrate the “cap” of intussusception in the terminal ileum (91. TREATMENT
There is one important point which we wouId Iike to emphasize in connection with the treatment of intussusception in ad&s: there is no place for conservative treatment or attempts at hydrostatic reduction by enemas. While this method of treatment is of benefit in infants and children in which the condition almost alwavs is primary or idiopathic, the opposite is true ‘rn adults. Benign or malignant tumors are the cause of intussusception in the majority of cases and in all three of our cases. Therefore, the removal of this causative agent is imperative. Exploratory laparotomy, usuahy through a right rectus type of incision, is mandatory. The intussusception is located and manuaI reduction is attempted by milking out the head of the intussusception from the lumen of the intussuscipiens. Exerting traction on the proximal segment is hazardous because of the danger of causing a rent in the friabIe bowel waI1. IIIustration of the technic of manual reduction is shown below. An ahernate method of reduction (described by Dr. Joe1 W. Baker in his discussion of the paper by Brayton and Norris [2] and ascribed to May and Normal) is introduction of a Foley catheter with the baboon collapsed, distally through the intussusception, if manual reduction is not easily performed. The balloon is then inflated, and the intussusception is more easiIy reduced by gentle traction with the Ieast amount of trauma. If reduction is obtained, the boweI is carefully inspected for possible gangrene and thoroughly searched for underlying tumor or other pathoIogy. An expIoratory enterotomy is justified after reduction in doubtfu1 cases. Benign poIyps or tumors may be removed through this enterotomy incision. In case of malignancy, resection with end to end anastomosis will be required; the extent of resection is dictated by the zone of suspected Iymphatic extension. If reduction is not possible by manipulation, resection of the intussusception is performed. The specimen is then examined carefuIIy for underIying pathoIogy. In cases of malignancy
in AduIts more radical resection continuity established anastomosis.
may be performed by an end to
and end
SUMMARY I. Intussusception in adults is an uncommon condition. 2. Intraluminal tumor is the most frequent cause of intussusception in adults, with smaI1 bowel tumors more commonly producing the intussusception. 3. The majority of coIon tumors producing intussusception are malignant (64 per cent as reported here). 4. In most cases the symptomatoIogy is that of a partial recurrent intestina1 obstruction. 5. The roentgenoIogic tindings are not aIways contributory to the diagnosis especiaIIy in the “pure enteric” type of intussusception. 6. The treatment of aduIt intussusception is surgical. The frequent coexistence of underIying pathology makes surgica1 exploration mandatory. 7. Three cases of intussusception in adults observed during the past five years at Mount Carmel Hospital have been presented.
REFERENCES
BOSWORTH,B. W. and STEIN, H. D. Intussusception in adults: report of a case due to aberrant pancreas. Am. J. Surg., 74: 801, 1987. W. J. Intussusception in 2. BRAYTON, D. and;Nonnrs, adults. Am. J. Surg., 88: 32, 1954. 3. DEAN, D. L., ELLIS, F. H. and SAUER, W. G. Intussusception in adults. Arch. Surg., 73: 6, I.
1956. 4. DONHAUSER,J. L. and KELLY, E. C. Intussusception in adults. Am. J. Surg., 79: 673, 1950. 5. DUNN, D. D. and SHEARBURN, E. W. JejunaI intussusception: unusual comphcation of the use of the Miller-Abbott tube. Surgery, 26: 830, 1949. I. S. Intussusception. Surgery, 36: 6. GOLDENBERG, 73% 1944. 7. LAWRENCE, G. H. and ULFELDER, H. Intussusception; a review of experience at the Massachusetts General Hospital, 1937-195 I. New England J. Med., 247: 499, 1952. in children and 8. ORLOFF, J. M. Intussusception ad&s. ~nternat. Abst. Surg., 102: 313, 1956. o. RIGLER. L. G. and GODFREY, H. W. The roentgen diagnosis of iIeoiIeaI intussusception. Am. J. Roentgenol., 79: 837, 1958. IO. ROPER, A. Intussusception in adults. Surg. Gynec. @ Ok., 103: 267, 1956. II. TEASDALE, D. H. Colocolic intussusception in the aduIt. &it. J. Surg., 41: 128, 1950. 12. WAGENSTEEN, 0. Intestinal Obstruction, 3rd ed., Chap. 22, p. 689. Springfield, III., 1955. Charles C Thomas Co.
113
in Adults
M.D. AND RICHARDW. ZOLLINGER, M.D., Columbus, Obio
F. BRIGGS, M.D., JOHN CARPATHIOS,
From tbe Department Columbus, Obio.
ofSurgery,Mount
Carmel Hospital,
type. In the iIeocecaI intussusception, the head of the cecum forms the head of the intussusceptum. As pointed out by Brayton and Norris [2] it is important to differentiate, in aduIts, between the iIeoceca1 and the iIeocoIic types since the causative Iesion in ileocolic intussusception is enteric and statisticaIIy much Iess IikeIy to be mahgnant than the iIeoceca1 type in which the Iesion originates from the cecum.
of the intestine is rare in aduhs. Therefore, the surgeon must reIy on the compilation of severa isoIated case reports if he is to attain some knowledge of the frequency of occurrence and the unusual features of the disease. During the years 1954 to 1959, there were 83,661 adult admissions to Mount CarmeI Hospital in Columbus, Ohio. There were four cases of adult intussusception in this group. We have reviewed three of them. The incidence we have found is simiIar to that reported by Donhauser and KeIIy [a]. Among the 242,829 patients admitted at the AIbany Hospital in New York during the years 1927 to 1947, there were twelve cases of intussusception in patients who were fifteen years of age or order.
I
NTUSSUSCEPTION
LOCATION
AND OCCURRENCE
Intussusception may occur anywhere in the gastrointestina1 tract beIow the gastric cardia. The reIative frequency of occurrence of intussusception at the various sites in 748 cases (four of which were muItipIe) is shown in Figure 2. This incIudes 665 cases reported by Donhauser and KelIy [4], 80 cases reported by Brayton and Norris [2], and the 3 cases reported herein. Gastrogastric and gastroduodenal intussusceptions represented 6 per cent of this series, enteric 40 per cent, iIeocoIic I3 per cent, iIeoceca1 16 per cent, appendicoceca1 4 per cent, coIocoIic 17 per cent and stoma1 4 per cent.
CLASSIFICATION Intussusception may be described as the invagination of a segment of the gastrointestina1 tract into an adjacent portion. The proxima1 segment usually invaginates into a dista1 portion; however, a retrograde type occasionaIIy may occur. An intussusception is primary (idiopathic) if no initiating pathology is found and secondary if an expIanatory lesion is discIosed. A compound intussusception is one in which there are more than the usua1 three cyIinders of a simpIe intussusception. Stoma1 intussusceptions occur as a comphcation of previous operative procedures such as gastrojejunostomy, coIostomy and ileostomy. The different types of intussusception can be divided into two main groups-enteric and cohc. These can be subdivided into four subtypes. (Fig. I.) They are iIeocoIic, iIeoceca1, colic and enteric. IIeocoIic is considered to be of the enteric type, while iIeoceca1 is of the colic
ENTERIC
FIG. I. Types of intussusception in ad&s. I09
American
Journal of Surgery,
Volume IOI. January
1961
Briggs,
Carpathios
and ZoIIinger TABLE I SITES
OF
RESPONSIBLE
MALIGNANT FOR
AND
BENIGN
Maiignant
TUMORS
(413
INTUSSUSCEPTION
Benign
CASES)
*
Caused by Tumor
Site
ILEOCOUC 13%
(No.)
ENTERIC 40 %
(%o)
____ APPENDICOCECAL40/eJ
FIG. 2. Sites of intussusception
(No.1
(%)
(No.1
(%o)
~--__
STOMAL 4 %
Gastric, duodenal. Enteric . Colic Total.
in adults.
ETIOLOGY
Of a11 intussusceptions, 5 to 7 per cent occur in aduIts [3,7,8,11]. The intussusceptions that occur in infants and chiIdren are predominateIy primary with no demonstrabIe cause (go to g5 per cent). In adults 80 per cent or more of the cases of intussusceptions are of a secondary nature, because they have a demonstrabIe cause. The causes of intussusception in the aduIt are many and varied. However, the vast majority (approximately 55 per cent) are initiated by tumors. The etioIogic factors in order of decreasing incidence are: benign tumors, malignant tumors, primary (idiopathic), Meckel’s diverticuIum, stomal, prolapse of gastric mucosa, chronic ulcerations in typhoid fever and tubercuIosis, .adhesions, aberrant pancreas [I], trauma, foreign body (incIuding Miller-Abbott tube), and miscellaneous (incIuding viscera1 purpura and mobile cecum). As previously stated, approximateIy 55 per cent of all intussusceptions are caused by tumors. It is aIso true that tumors are the etiologic factor in 6 per cent of the intussusceptions invoIving the gastroduodena1 segment, 54 per cent of the enteric area and in 40 per cent of those affecting the colon. (Table I.) The incidence of malignancy of tumors in these regions was 15 per cent for the gastroduodena1 segment, 28 per cent for the small bowel portion, and in 64 per cent of those in the colonic areas. The mechanism invoIved in the production of an intussusception of the idiopathic or primary type is postuIated as being a proximal wave of contraction adjacent to a distal segment of relaxation. In a secondary intussusception a lesion apparently is responsible for starting an invagination by acting as a focus of stimulation of muscular contraction causing an
. .
3 62
I5 28
IO7 ‘72
64 4I
18
85
6
21
I63 60 241
72 36 59
54 40 413
225 I67 100
* Modified from Roper [IO].
increased peristaIsis of the intestine and, thus, teIescoping invagination of one segment into an adjacent portion. The Iumen of the invaginated bowel (intussusceptum) is narrowed but rareIy compIeteIy obstructed [12]. The mesentery and wa1Is of the intussusceptum become compressed and edematous and further aggravation of the degree of obstruction ensues. Acute intussusceptions rapidly tend to become irreducibIe due to these changes and ulceration, and gangrene and perforation of the intussusception may occur. CASE
REPORTS
CASE I. F. W., a forty-eight year old pharmacist, was admitted to Mount Carmel Hospital on JuIy zg, 1959. Approximately eight hours previously he experienced acute onset of severe periumbilical pain which was accompanied by nausea, vomiting and moderate abdominal distention. His symptoms persisted and were progressive at the time of admission. Similar episodes of abdominal pain with nausea and vomiting which terminated spontaneously and were less severe had occurred in February and again in June of 1959. There had been no hematemesis or melena. He had been given antacids and antispasmodics for peptic uIcer, which had not been documented by prior X-ray examination. He had undergone no previous surgery. On admission there was Iocalized distention of the left upper quadrant with tenderness over the area of distention and rebound tenderness. The abdomen was soft in the other quadrants and there was no guarding. Bowel sounds were absent except for high-pitched sounds over the area of distention. Supine and upright X-ray films of the abdomen disclosed dilatation of small bowe1 loops in the upper abdomen. The chest fiIm was not remarkable. 110
Intussusception
in AduIts with 5 per cent nonsegmented neutrophiIs, 4g per cent segmented neutrophiIs, 45 per cent Iymphocytes and I per cent monocytes. The serum amylase was 136 Somogyi units. The admitting diagnosis was perforated duodena1 ulcer. ApproximateIy eight hours folIowing the onset of his symptoms, an exploratory abdomina1 Iaparotomy was performed through a right upper rectus incision. There was no free air in the peritonea1 cavity, and the stomach and duodenum appeared normal. The smaI1 bowe1 was explored and in the Ieft lower quadrant there was a dilated, firm Ioop which revealed an enteric intussusception of the proximal ileum when it was delivered from the abdomen. The circuIation of the invoIved bowel was not seriously compromised and the intussusception which involved approximately eighteen inches of jejunum and proximal ileum was reduced. An intraluminal poIyp (3 cm.) was found to be Ieading the intussusception. The polyp was resected in its entirety through a IongitudinaI enterotomy. The tumor appeared to be benign. However, a diagnosis of infiltrating mutinous adenocarcinoma was made from permanent microscopic sections. Much of the mass forming the polyp was actuaIIy tumor invading serosal fat. The patient passed bright red bIood per rectum on his first three postoperative days. His hemogIobin feI1 to 6.6 gm. per cent and he was transfused with 1,500 cc. of whoIe blood. The bIeeding ceased and the patient did well. On December I 7, I 956, an upper gastrointestina1 series was obtained to ruIe out the presence of further polyps of large or smaI1 bowe1. None was found; however, the suggestion of a duodena1 uIcer was seen. The patient was discharged on December 19, 1956 without further compIication. He was readmitted on January 13, 1957 and underwent a segmenta resection of the iIeum at the site of the previous enterotomy. No evidence of maIignancy was found in the specimen. An end to end anastomosis was performed. The patient did we11 and was discharged on his tenth postoperative day.
Admission Iaboratory tests reveaIed that the hemoglobin was 14 gm. per cent, hematocrit was 43 per cent, the leukocyte count was I 1,200 per cu. mm. with z per cent nonsegmented neutrophils, 82 per cent segmented neutrophiIs, and 16 per cent Iymphocytes. The serum amyIase, serum electrolytes, prothrombin time, bIood urea nitrogen and urinalysis were within norma Iimits. : ,The admission diagnosis was mechanica obstruction of the smaI1 bowel. An expIoratory abdominal Iaparotomy was performed tweIve hours after admission. The abdomen was opened through a right paramedian rectus incision immediateIy reveaIing a greatIy diIated Ioop of smal1 bower approximateIy fourteen inches in Iength which was approximately three feet proxima1 to the iIeoceca1 valve. An enteric intussusception was found and reduced manually. FolIowing reduction, it was found that the leading point of the intussusception was a mass extending from the serosa of the bowe1 which was continuous with a poIypoid intraluminal mass. There was no compromise of the circulation. However, the mesentery was Iigated segmentally. The bowel was transected proximal and distal to the tumor which was removed with the ileum anastomosed end to end. Microscopic examination reveaIed a bizarre, IocaIIy invasive, non-epitheIia1 type of tumor of the intestina1 waI1, probabIy arising from muscIe. It was not encapsuIated and the overIying mucosa was uIcerated. The patient did we11 postoperativeIy and was discharged on his seventh postoperative day. CASEII. J. M., a thirty year old insurance agent, was admitted to Mount CarmeI Hospital on December 7, 1956, approximateIy three hours foIIowing the acute onset of upper abdomina1 pain. The patient had a history of proven peptic uIcer in 1947 which was treated medicaIly with the cessation of symptoms. He had enjoyed good health from 1947 unti1 the day of admission when his chief compIaint was an epigastric, coIicky pain, accompanied by nausea, vomiting and Iassitude. He had a norma bowel movement the day of admission. The patient had had an appendectomy in the remote past. On admission, the patient had a rigid abdomen with severe upper abdominal pain and tenderness in the Iower abdomen as weI1, more marked in the right Iower abdominal quadrant. No masses were paIpabIe in the abdomen. The bowe1 sounds were hypoactive. Rdentgenograms of the chest as we11 as upright and supine fiIms of the abdomen revealed no abnormaIity. Admission Iaboratory work reveaIed that the hemoglobin was I I .7 gm. per cent, hematocrit was 40 per cent, and the leukocyte count was 17,000
CASE III. L. K., a seventy-one year oId man, entered Mount CarmeI Hospital on June 3, 1958 with a three week history of coIicky, Iower abdominaI pain with associated diarrhea and occasiona1 bright red streaking in his stoo1. There had been a few episodes of nausea with vomiting and a weight Ioss of ten pounds during the same period. On admission the patient’s abdomen was slightIy distended and tympanitic, but the bowe1 sounds were reportedty normal. There was some guarding and tenderness in the lower abdomen with a tendency to IocaIization in the right Iower quadrant. No abdominal mass was paIpabIe. Barium enema examination showed obstruction III
Briggs, Carpathios
and ZoIIinger
FIG. 4. The resected specimen (Case III). The transverse colon is opened over the leading point of the intussusception reveaIing the submucosa1
Iipoma.
surgica1 specimen was opened, revealing a submucosa1 Iipoma of the distal ileum which had Ied to the intussusception. (Fig. 4.) The patient recovered from the procedure without event and was discharged on his seventh postoperative day. DIAGNOSIS
FIG. 3. Barium enema (Case III) demonstrating a filling defect in the proxima1 transverse colon which represents the Iarge submucosal Iipoma. Note the typical “coiled spring” appearance.
The clinica diagnosis of intussusception is unfortunateIy seIdom suspected and so it is missed, due to the rarity of the condition in ad&s. The usua1 history is that of a chronic recurrent partial intestina1 obstruction. Intermittent abdomina1 coIicky pain is the most common symptom. Nausea, vomiting and obstipation enter into the clinica picture as the obstruction graduaIIy becomes compIete. Blood and mucous in the stoo1 occurs Iess often in aduIts than in infants [3,8]. In two of our three cases this symptom was absent. PaIpabIe abdomina1 tumor also is an unreIiabIe finding because it may or may not be present. This finding was absent in our three cases. A ffat fiIm of the abdomen may show evidence of bowe1 obstruction by demonstrating the diIated intestina1 loops. A barium enema may demonstrate the characteristic “coiIed spring” appearance in cases of iIeocolic or colocolic types of intussusception. This appearance is due to the passage of barium around the convex head of the intussusception with flow of barium between the foIds of the mucosa of the intussuscipiens:where it ensheaths the head of the intussusception. A mushroom or crescentic appearance may aIso be seen at the point of obstruction. These signs are usuaIIy of no vaIue in the “enteric” cases (iIeoiIea1, jejunoiIea1) of intussusception, since they are dependent en-
of the proximal transverse colon with the appearance of intussusception. (Fig. 3.) A poIyp of the distaI ileum had been demonstrated three weeks prior to hospitalization by prior barium enema. Therefore, the admitting diagnosis was iIeocoIic intussusception. On June 9, 1958 expIoratory surgery was performed through a right midrectus incision. A huge iIeocoIic intussusception was encountered invoIving iIeum, cecum and ascending coIon. Because of the inflammatory changes and the inabiIity to reduce the intussusception, a right hemicolectomy and iIeo-transverse colostomy was performed. The
FIG. 5. Operative reduction of intussusception
in aduIts. II2
Intussusception tireIy on refIux through the ileocecal valve into the terminal iIeum and only in rare instances does regurgitation of the barium enema through an incompetent ileocecal valve demonstrate the “cap” of intussusception in the terminal ileum (91. TREATMENT
There is one important point which we wouId Iike to emphasize in connection with the treatment of intussusception in ad&s: there is no place for conservative treatment or attempts at hydrostatic reduction by enemas. While this method of treatment is of benefit in infants and children in which the condition almost alwavs is primary or idiopathic, the opposite is true ‘rn adults. Benign or malignant tumors are the cause of intussusception in the majority of cases and in all three of our cases. Therefore, the removal of this causative agent is imperative. Exploratory laparotomy, usuahy through a right rectus type of incision, is mandatory. The intussusception is located and manuaI reduction is attempted by milking out the head of the intussusception from the lumen of the intussuscipiens. Exerting traction on the proximal segment is hazardous because of the danger of causing a rent in the friabIe bowel waI1. IIIustration of the technic of manual reduction is shown below. An ahernate method of reduction (described by Dr. Joe1 W. Baker in his discussion of the paper by Brayton and Norris [2] and ascribed to May and Normal) is introduction of a Foley catheter with the baboon collapsed, distally through the intussusception, if manual reduction is not easily performed. The balloon is then inflated, and the intussusception is more easiIy reduced by gentle traction with the Ieast amount of trauma. If reduction is obtained, the boweI is carefully inspected for possible gangrene and thoroughly searched for underlying tumor or other pathoIogy. An expIoratory enterotomy is justified after reduction in doubtfu1 cases. Benign poIyps or tumors may be removed through this enterotomy incision. In case of malignancy, resection with end to end anastomosis will be required; the extent of resection is dictated by the zone of suspected Iymphatic extension. If reduction is not possible by manipulation, resection of the intussusception is performed. The specimen is then examined carefuIIy for underIying pathoIogy. In cases of malignancy
in AduIts more radical resection continuity established anastomosis.
may be performed by an end to
and end
SUMMARY I. Intussusception in adults is an uncommon condition. 2. Intraluminal tumor is the most frequent cause of intussusception in adults, with smaI1 bowel tumors more commonly producing the intussusception. 3. The majority of coIon tumors producing intussusception are malignant (64 per cent as reported here). 4. In most cases the symptomatoIogy is that of a partial recurrent intestina1 obstruction. 5. The roentgenoIogic tindings are not aIways contributory to the diagnosis especiaIIy in the “pure enteric” type of intussusception. 6. The treatment of aduIt intussusception is surgical. The frequent coexistence of underIying pathology makes surgica1 exploration mandatory. 7. Three cases of intussusception in adults observed during the past five years at Mount Carmel Hospital have been presented.
REFERENCES
BOSWORTH,B. W. and STEIN, H. D. Intussusception in adults: report of a case due to aberrant pancreas. Am. J. Surg., 74: 801, 1987. W. J. Intussusception in 2. BRAYTON, D. and;Nonnrs, adults. Am. J. Surg., 88: 32, 1954. 3. DEAN, D. L., ELLIS, F. H. and SAUER, W. G. Intussusception in adults. Arch. Surg., 73: 6, I.
1956. 4. DONHAUSER,J. L. and KELLY, E. C. Intussusception in adults. Am. J. Surg., 79: 673, 1950. 5. DUNN, D. D. and SHEARBURN, E. W. JejunaI intussusception: unusual comphcation of the use of the Miller-Abbott tube. Surgery, 26: 830, 1949. I. S. Intussusception. Surgery, 36: 6. GOLDENBERG, 73% 1944. 7. LAWRENCE, G. H. and ULFELDER, H. Intussusception; a review of experience at the Massachusetts General Hospital, 1937-195 I. New England J. Med., 247: 499, 1952. in children and 8. ORLOFF, J. M. Intussusception ad&s. ~nternat. Abst. Surg., 102: 313, 1956. o. RIGLER. L. G. and GODFREY, H. W. The roentgen diagnosis of iIeoiIeaI intussusception. Am. J. Roentgenol., 79: 837, 1958. IO. ROPER, A. Intussusception in adults. Surg. Gynec. @ Ok., 103: 267, 1956. II. TEASDALE, D. H. Colocolic intussusception in the aduIt. &it. J. Surg., 41: 128, 1950. 12. WAGENSTEEN, 0. Intestinal Obstruction, 3rd ed., Chap. 22, p. 689. Springfield, III., 1955. Charles C Thomas Co.
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