This document summarizes a retrospective review of 22 cases of adult intussusception encountered at two hospitals between 1989 and 2000. The average age was 57 years and abdominal pain was the most common symptom. 86% of cases had an identifiable lesion. Small bowel lesions were more often benign (64%) while large bowel lesions were frequently malignant (50%). Surgical intervention was required in all cases except one, with reduction attempted for small bowel intussusceptions when possible but resection typically used for large bowel intussusceptions due to higher risk of malignancy. The review supports reduction of small bowel intussusceptions before resection if benign but resection of large bowel intussusceptions due to higher cancer rates.

1. Adult Intussusception:
A Retrospective Review
Ahmad Zubaidi, M.D., F.R.C.S.C., Faisal Al-Saif, M.D., F.R.C.S.C.,
Richard Silverman, M.D., F.R.C.S.C.
Department of Surgery, Saint Boniface Hospital, Winnipeg, Manitoba, Canada
PURPOSE: Whereas intussusception is relatively common
in children, it is clinically rare in adults. The condition is
usually secondary to a definable lesion. This study was de-
signed to review adult intussusception, including presenta-
tion, diagnosis, and optimal treatment. METHODS: A
retrospective review of 22 cases of intussusception occur-
ring in individuals older than aged 18 years encountered at
two university-affiliated hospitals in Winnipeg between
1989 and 2000. The 22 cases were divided to benign and
malignant enteric, ileocolic, colonic lesions respectively.
The diagnosis and treatment of each case were reviewed.
RESULTS: There were 22 cases of adult intussuscep-
tion. Mean age was 57.1 years. Abdominal pain, nausea, and
vomiting were the commonest symptoms. There were 14
enteric, 2 ileocolic, and 6 colonic intussusceptions. Eighty-
six percent of adult intussusception was associated with a
definable lesion. Twenty-nine percent of enteric lesions
were malignant. All ileocolic lesions were malignant. Of
colonic lesions, 33 percent were malignant and 67 percent
were benign. All cases required surgical interventions
except one. CONCLUSIONS: Adult intussusception is a rare
entity and requires a high index of suspicion. Our review
supports that small-bowel intussusception should be reduced
before resection if the underlying etiology is suspected to
be benign or if the resection required without reduction
is deemed to be massive. Large bowel should generally be re-
sected without reduction because pathology is mostly malig-
nant. [Key words: Adult intussusception; Ileocolic; Colocolic;
Rectocolic; Rectorectal; Meckel_s diverticulum; Bowel ob-
struction; Barium enema; CT scan; Colonoscopy; Flexible
sigmoidoscopy]
Intussusception was first reported in 1674 by
Barbette of Amsterdam.1
In 1789, John Hunter
gave a detailed report about intussusception, or
FFintrosusception__ as it was called then.2
Sir Jonathan
Hutchinson3
was the first to successfully operate on a
child with intussusception in 1871. Intussusception is
defined as the telescoping of a segment of the gas-
trointestinal tract into an adjacent one. It is the leading
cause of intestinal obstruction in children and ranks
second only to appendicitis as the most common
cause of acute abdominal emergency in children.4
The rarity of this disease in adults is demonstrated
by the fact that only 22 cases were found in the
records of two major hospitals in Winnipeg, serving
a population of 700,000 during the period from 1989
to 2000.
The exact mechanism that precipitates intussus-
ception is still unknown, but it is generally believed
that any lesion in the bowel wall or irritant within the
bowel lumen may alter the normal peristaltic pattern
and is capable of starting an invagination leading to
intussusception.5
The optimal surgical approach in
adult intussusception (AI) has been controversial in
the past. More recently, manual reduction of the
intussusception followed by definitive surgical resec-
tion has been advocated. Sanders and colleagues6
and Brayton and Norris7
recommended primary re-
section without attempting reduction in all adult
patients with intussusception, regardless of anatomic
site, because of significant risk of associated malig-
nancy, which approaches 65 percent.8
Thus, a con-
troversy continues to focus on whether AI should be
Correspondence to: Ahmad Zubaidi, M.D., F.R.C.S.C., Foot Hills
Medical Center, Department of Surgery, 1403-28 St. N.W., Calgary,
Alberta T2N 2T9, Canada, e-mail: azubaidi@ucalgary.ca
Dis Colon Rectum 2006; 49: 1546–1551
DOI: 10.1007/s10350-006-0664-5
* The American Society of Colon and Rectal Surgeons
Published online: 22 September 2006
1546

2. surgically resected without an attempt at reduction for
fear that undue operative manipulation of a malig-
nant lesion may result in tumor dissemination.9
PATIENTS AND METHODS
The records of all patients aged 18 years or older
admitted to St. Boniface Hospital and Health Sciences
Center in Winnipeg between 1989 and 2000 were re-
viewed retrospectively. Patients with rectal or stomal
prolapse, appendiceal, and gastrojejunal intussuscep-
tions were excluded from this review. A total of 22
patients were identified and were classified into five
categories on the basis of the location of the lead point
of the intussusception:
1. Enteric, in which the intussusception is con-
fined to the small bowel.
2. Ileocolic, ileum invaginates through ileocecal
valve.
3. Colocolic, in which the intussusception is
confined to the colon.
4. Colorectal, colon invaginates through rectal
ampulla.
5. Rectorectal, as internal intussusception with no
anal protrusion.
For each category, date, age, gender, clinical fea-
tures, and the results of diagnostic studies were
documented. Operative and pathologic records were
reviewed to determine the location and viability of
the involved segment, method of surgical manage-
ment, and postoperative outcome.
RESULTS
Age and Gender Data
There was a slight female predominance in our
study: 13 females (59 percent), and 9 males (41
percent). The youngest patient in this series was
aged 19 years and the oldest was aged 93 (mean,
57.1) years.
Clinical Manifestations
Pain was the most common presenting complaint
and was present in 19 patients (86 percent). Nausea,
vomiting, constipation, bleeding per rectum, and
diarrhea were other symptoms (Table 1). A palpable
mass was found in only 9 percent (2 patients). The
symptoms and signs of acute intestinal obstruction
were present in only one-half of patients. The rest of
the patients presented with more chronic symptoms
during a period of weeks to months. Eight patients
had previous abdominal surgeries.
Diagnostic Studies
Seventeen patients (77 percent) had plain abdom-
inal x-rays as part of their evaluation (Table 2). The
signs of intussusception were multiple air fluid levels
and a questionable mass. Two patients had abdominal
ultrasound with confirmation of intussusception in
one. CT scanning was used more frequently (6/22
patients), and it showed clear signs of intussusception
only in one patient. CT scanning showed a mass in
four patients but failed to diagnose it as an intussus-
ception. Contrast studies were performed in 13
patients. Seven patients had a barium enema, which
confirmed intussusception in four. Upper GI series
was performed in six patients and was able to confirm
the diagnosis of small-bowel intussusception preop-
eratively in only one patient. Colonoscopy was per-
formed in seven patients. In one patient, colonoscopy
was performed with the intention of reducing the
intussusception. Overall, the diagnosis of intussus-
ception was suspected preoperatively in only three
patients (14 percent). More patients with enteric
intussusception had plain abdominal x-ray and upper
GI series, whereas patients with ileocolic and colonic
intussusception had more barium and endoscopic
evaluation.
Location
The majority of intussusceptions were in the small
bowel (14/22 or 64 percent). There were two (9
percent) cases of ileocolic intussusception and six
(27 percent) cases of colonic intussusceptions.
Table 1.
Symptoms and Signs
Pain 19 (86.4)
Nausea 13 (59)
Vomiting 13 (59)
Constipation 5 (22.7)
Bleeding per rectum 3 (27.3)
Diarrhea 2 (9.1)
Abdominal mass 2 (9.1)
Fever 1 (4.5)
Data are numbers with percentages in parentheses.
Vol. 49, No. 10 REVIEW OF ADULT INTUSSUSCEPTION 1547

3. Pathology
The pathologic cause of intussusception was identi-
fied in 19 cases (Table 3). Benign pathologies were seen
in 14 cases (64 percent) and malignant in 8 patients (36
percent). Of small-bowel intussusceptions, ten were
secondary to a benign process, including submucosal
lipoma, leiomyoma, and rupture of small-bowel aneu-
rysm, intussuscepting Meckel_s diverticulum, and post-
operative adhesions. No pathology could be
demonstrtated in one case. Of the malignant causes,
two were caused by metastatic melanoma: one was
secondary to adenocarcinoma, and one was secondary
to a primary small-bowel leiomyosarcoma.
Fifty percent of large-bowel intussusceptions were
a result of a malignant lesion. The causes of both
ileocolic intussusceptions were primary adenocarci-
noma (2 cases). Cases of colonic intussusception
were secondary to primary adenocarcinoma (1 case),
metastatic lymphoma (1 case), lipoma (1 case),
adhesion (1 case), and idiopathic (2 cases). No
colorectal or rectorectal intussusception cases were
identified in this study.
Treatment
Twenty patients in our series underwent laparoto-
my. One patient underwent laparoscopy as a diag-
nostic and therapeutic procedure, and only one
patient improved without any surgical intervention.
No 30-day mortality was encountered in this review.
Among 14 patients with small-bowel intussuscep-
tion, intraoperative reduction before resection was
attempted in six patients. It was successful in only
one. The failure in five patients was believed to be
caused by fixation from intense adhesions or con-
cerns that reduction would result in perforation.
There were two patients with ileocolic intussuscep-
tion. One patient underwent formal resection. The
other patient was known to have an indeterminate
Table 3.
Lesions Associated With Adult Intussusception
Causes No. of cases (%) Small Bowel Ileocolic Colonic
Benign
Adhesion (postoperative) 6 (27.3) 5 0 1
Idiopathic 3 (13.6) 1 0 2
Lipoma 2 (9.1) 1 0 1
Ruptured aneurysm 1 (4.5) 1 0 0
Meckel_s diverticulum 1 (4.5) 1 0 0
Leiomyoma 1 (4.5) 1 0 0
Malignant
Primary
Adenocarcinoma 4 (18.2) 1 2 1
Leiomyosarcoma 1 (4.5) 1 0 0
Secondary
Metastatic melanoma 2 (9.1) 2 0 0
Lymphoma 1 (4.5) 0 0 1
Total 22 (100) 14 2 6
Data are numbers with percentages in parentheses.
Table 2.
Efficacy of Diagnostic Procedures
Procedure No. of cases (%) Intussusception Mass Obstruction Negative
Plain AXR 17 (77.3) 0 1 (5.9) 15 (88.2) 1 (5.9)
Upper GI series 6 (27.3) 1 (16.7) 1 (16.7) 4 (16.7) 1 (16.7)
Barium enema 7 (31.8) 4 (57.1) 1 (14.3) 1 (14.3) 1 (14.3)
Ultrasound-
abdomen
2 (9.1) 1 (50) 1 (50) 0 0
Colonoscopy 7 (31.8) 1 (14.3) 4 (57.1) 0 2 (28.6)
CT scan-
abdomen
6 (27.3) 1 (16.7) 4 (66.7) 5 (83.3)a
1 (16.7)
Meckel_s scan 1 (5.4) 0 0 0 1 (100)
AXR = abdominal x-ray; GI = gastrointestinal.
Data are numbers with percentages in parentheses.
a
Includes four cases that had a mass and one case that had intussusception.
1548 ZUBAIDI ET AL Dis Colon Rectum, October 2006

4. grade lymphoma of the small bowel and a history of
recurrent episodes of abdominal pain, nausea, and
vomiting. CT scan of the abdomen was suggestive of an
ileocecal intussusception. Therapeutic barium enema
was performed, and reduction of the intussusception
was successful. The patient subsequently underwent
chemotherapy and ultimately succumbed secondary to
his comorbid condition.
In the colocolic intussusception group, preoperative
endoscopic reduction of the intussusception was at-
tempted in one patient, a 68-year-old female who pre-
sented with iron-deficiency anemia and fecal occult
blood positive stools. Subsequently she underwent
barium enema, which showed evidence of intussus-
ception in the ascending colon. Colonoscopy was then
performed in an attempt to diagnose and reduce the
intussusception, which was unsuccessful. Therefore, a
laparotomy and right hemicolectomy were performed.
There was no evidence of malignancy or any other
identifiable lesion in the specimen. Intraoperative re-
duction before segmental resection was performed in
one patient and was successful. The rest underwent
resection without prior reduction.
DISCUSSION
Intussusception is uncommon in adults compared
with the pediatric population. It is estimated that only 5
percent of all intussusceptions occur in adults and
approximately 5 percent of bowel obstructions in
adults are the result of intussusception.10
In > 90 per-
cent of cases, an identifiable lesion resulting in a lead
point is demonstrable,11
with neoplasm accounting
for 65 percent.12
Therefore, AI requires surgical
management tailored to the most highly suspected
pathology. In this study, we reviewed our experience
in adult intussusception by means of a retrospective
chart review involving two teaching hospitals during
an 11-year period.
The clinical presentation of adult intussusception
varies considerably. The most common presenting
symptoms are abdominal pain, nausea, and emesis in
the acute presentation, seen in only 20 percent of AI.13
Intermittent abdominal pain and vomiting are the
major symptoms of subacute or chronic AI.12
The
classic pediatric presentation of intussusception, ab-
dominal pain, mass, blood per rectum, is rarely found
in adults in general,5,8 –10,14
and we have not encoun-
tered this triad in any of our patients. Other findings
are fever, constipation, diarrhea, bleeding, and
abdominal distention.5,8,9
Common physical findings
include abdominal distention, decreased or absent
bowel sounds, guaiac-positive stool, and abdominal
mass.5,8 –10,14
Because of the variability in clinical pre-
sentation and the impreciseness of diagnostic imaging,
it is not uncommon for the diagnosis to be made only
at the time of laparatomy.10
Several imaging techniques may help to precisely
identify the causative lesion preoperatively. Plain ab-
dominal x-ray is typically the first diagnostic tool.
Contrast studies can help to identify the site and cause
of the intussusception, particularly in more chronic
cases. Upper gastrointestinal series may show Bstacked
coin’’ or Bcoiled spring’’ appearance.9
Barium enema
examination may be useful in patients with colonic or
ileocolic intussusception in which a cup-shaped filling
defect is a characteristic finding.9
Barium enema was
diagnostic in four patients and both diagnostic and
therapeutic in one patient in this series.
Ultrasonography has been used to evaluate sus-
pected intussusception. The classic features include
the target and doughnut sign on transverse view and
the pseudokidney sign in the longitudinal view.10,15
In our study, ultrasound was used on two occasions
and it was diagnostic in one patient who had an
adenocarcinoma of the ileocolic region. The major
disadvantage of ultrasound is masking by gas-filled
loops of bowel and operator dependency.10,16
The characteristic features of CT scan include a
target mass enveloped with eccentrically located
areas of low density. Later a layering effect occurs
as a result of longitudinal compression and venous
congestion of the intussusception.10
In our study, six
patients had abdominal CT scans preoperatively.
Although abdominal CT scan has been reported to
be the most useful imaging modality,11
intussuscep-
tion was diagnosed in only one patient in this series,
who had ileocolic intussusception. The pathology
report confirmed the presence of adenocarcinoma in
the intussuscepting mass. A mass was diagnosed in
four other patients, and CT scan was negative in one
patient. Abdominal CT scan has been shown to be a
useful test in evaluating these patients, particularly
when a mass is present on physical examination. It
may define the location, the nature of the mass, its
relationship to the surrounding tissues, and it may
stage the patient with suspected malignancy causing
the intussusception.9
Flexible sigmoidoscopy and colonoscopy are of
paramount importance in evaluating intussusception
presenting with subacute or chronic large-bowel
Vol. 49, No. 10 REVIEW OF ADULT INTUSSUSCEPTION 1549

5. obstruction.10
Colonoscopy was used in seven of our
patients as a diagnostic tool. Although it was able to
demonstrate the presence of an obstructing mass, it
succeeded in diagnosing an intussusception in only
one patient. It may not be advisable to perform endo-
scopic biopsy or polypectomy in those individuals
with long-term symptoms because of the high risk of
perforation, which is more likely to happen in the
phase of chronic tissue ischemia and perhaps necrosis
because of vascular compromise in intussusception.17
There is no universal approach to the treatment of
adult intussusception. Most authors agree that lapa-
rotomy is mandatory, based on the likelihood of an
underlying pathologic lesion.14
There has been
controversy associated with the option of preliminary
reduction of the intussusception before resection vs.
primary resection without reduction. The theoretic
objections to reduction of grossly viable bowel with
mucosal necrosis are: 1) intraluminal seeding and
venous embolization of malignant cells in the region
of ulcerated mucosa,16
2) possible perforation during
manipulation,5,9
3) increased risk of anastomotic
complications in the face of edematous and inflamed
bowel.5,9
Reduction should not be attempted if there
are signs of bowel ischemia or inflammation.11
Based
on a high incidence of an underlying malignancy,
which may be difficult to confirm intraoperatively,
many authors recommend primary resection when-
ever possible.5,14
For colonic intussusception, most
recent reports recommend a selective approach to
resection, keeping in mind that the site of intussus-
ception tends to correlate with the lesion being
benign or malignant.9,10
Adults with intussusception have an organic lesion
within the intussusception in 70 to 90 percent of cases.
In 20 to 50 percent, the etiologic agent is a malignan-
cy.14,16,18
In our review, 36 percent of patients
harbored malignant lesions. If the large bowel only
is considered, then the likelihood of cancer is 50–65
percent. The vast majority of these lesions arises as a
primary lesion, in which resection without reduction
is recommended.5,8 – 10,14
The exception to this rule
may be in the case of sigmoidorectal intussusception
secondary to a carcinoma, in which reduction before
the resection may save the patient an abdominoper-
ineal resection and a permanent colostomy. Howev-
er, even this option remains controversial.
For small-bowel intussusception, initial reduction
of externally viable bowel before resection is recom-
mended in recent reports.9,19
The incidence of
malignancy as the cause of small intestinal intussus-
ception ranges from 1 to 40 percent, and the vast
majority are metastatic.5,8 –10,14
Thus, the recommen-
dation of initial reduction and then resection allow-
ing bowel preservation is prudent.
CONCLUSIONS
Intussusception in adults is an infrequent problem.
However, it is a challenging condition that requires
the surgeon to understand its epidemiology and treat-
ment options. Diagnosis is difficult because of non-
specific and often subacute symptoms with absence of
pathognomonic clinical signs. It is important to have a
high index of suspicion. There is no Bgold standard’’
diagnostic test and most cases are diagnosed during
laparotomy.
Treatment usually requires resection of the in-
volved bowel segment. Reduction can be attempted
in small-bowel intussusception if the segment in-
volved is viable or malignancy is not suspected; how-
ever, a more careful approach is recommended in
colonic intussusception because of a significantly
higher chance of malignancy. Therapeutic barium
enema can be tried in a few selected cases where the
underlying pathology is known.
REFERENCES
1. de Moulin D. Paul Barbette, M.D.: a seventeenth-
century Amsterdam author of best-selling textbooks.
Bull Hist Med 1985;59:506–14..
2. Noble I. Master surgeon: John Hunter. New York: J.
Messner, 1971:185.
3. Hutchinson H, Hutchinson J, et al. Jonathan Hutch-
inson, life and letters. London: W. Heinemann Medical
Books, 1946.
4. Akcay MN, Polat M, Cadirci M, et al. Tumor-induced
ileo-ileal invagination in adults. Am Surg 1994;60:980–1.
5. Weilbaecher D, Bolin JA, Hearn D, et al. Intussuscep-
tion in adults. Review of 160 cases. Am J Surg 1971;
121:531–5.
6. Sanders GB, Hagan WH, Kinnaird DW. Adult intus-
susception and carcinoma of the colon. Ann Surg
1958;147:796–804.
7. Brayton D, Norris WJ. Intussusception in adults. Am J
Surg 1954;88:32–43.
8. Nagorney DM, Sarr MG, McIlrath DC. Surgical man-
agement of intussusception in the adult. Ann Surg
1981;193:230–6.
9. Eisen LK, Cunningham JD, Aufses AH Jr. Intussuscep-
1550 ZUBAIDI ET AL Dis Colon Rectum, October 2006

6. tion in adults: institutional review. J Am Coll Surg 1999;
188:390–5.
10. Begos DG, Sandor A, Modlin IM. The diagnosis and
management of adult intussusception. Am J Surg 1997;
173:88–94.
11. Tan KY, Tan SM, Tan AG, et al. Adult intussusception:
experience in Singapore. ANZ J Surg 2003;73:1044–7.
12. Haas EM, Etter EL, Ellis S, et al. Adult intussusception.
Am J Surg 2003;186:75–6.
13. Warshauer DM, Lee JK. Adult intussusception detected
at CT or MR imaging: clinical-imaging correlation. Radi-
ology 1999;212:853–60.
14. Azar T, Berger DL. Adult intussusception. Ann Surg
1997;226:134–8.
15. Weissberg DL, Scheible W, Leopold GR. Ultrasono-
graphic appearance of adult intussusception. Radiology
1977;124:791–2.
16. Reijnen HA, Joosten HJ, de Boer HH. Diagnosis and
treatment of adult intussusception. Am J Surg 1989;
158:25–8.
17. Chang FY, Cheng JT, Lai KH. Colonoscopic diagnosis
of ileocolic intussusception in an adult. A case report. S
Afr Med J 1990;77:313–4.
18. Bar-Ziv J, Solomon A. Computed tomography in adult
intussusception. Gastrointest Radiol 1991;16:264–6.
19. Yalamarthi S, Smith RC. Adult intussusception: case
reports and review of literature. Postgrad Med J 2005;
81:174–7.
Vol. 49, No. 10 REVIEW OF ADULT INTUSSUSCEPTION 1551