Nigerian Postgraduate Medical Journal

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 26  |  Issue : 3  |  Page : 169--173

An appraisal of the presentation and management of adult intussusception at a Nigerian Tertiary Hospital


Olanrewaju Samuel Balogun, Thomas O Olajide, Michael Afolayan, Abdulrazzak Lawal, Adedapo Olumide Osinowo, Adedoyin A Adesanya 
 Department of Surgery, College of Medicine, University of Lagos and Lagos University Teaching Hospital, Lagos, Nigeria

Correspondence Address:
Dr. Olanrewaju Samuel Balogun
Department of Surgery, College of Medicine, University of Lagos, Lagos
Nigeria

Abstract

Background: Intussusception in adults is considered rare in surgical practice. It is the causative lesion in a small proportion of cases of intestinal obstruction and lower gastrointestinal bleeding. In the last decade, the incidence of adult intussusception appears to be increasing at our centre. Aims: This study aims to document the pattern of presentation and management outcome of adult intussusception at our institution during the last decade. We also observed the occurring trends of this lesion. Patients and Methods: This was a 10-year retrospective study of consecutive adult patients with intussusception seen at our institution from July 2008 to June 2018. Information on biodata, clinicopathological features and management outcome retrieved from case notes and pathology records were analysed on a personal computer using SPSS version 23. Results: Twenty adult patients who had intussusception were seen during this period. There were 9 (45%) males and 11 (55%) females giving a male-to-female ratio of 1:1.2. The mean age of presentation was 45 (range 18–66) years. Clinical features were abdominal pain (85%), abdominal distension (80%), vomiting (70%), rectal bleeding (70%) and palpable abdominal mass (35%). Majority of patients (70%) presented with features of intestinal obstruction. Idiopathic intussusception (55%) accounted for more than half of the cases with the jejunoileal variety (30%) as the most common pathological type. One patient who had intussusception in the postoperative period was treated with manual reduction at laparotomy. Bowel resections were performed in the remaining 19 (95%) patients. Conclusion: Adult intussusception is still uncommon in our general surgical practice. Bowel resection is the mainstay of treatment.



How to cite this article:
Balogun OS, Olajide TO, Afolayan M, Lawal A, Osinowo AO, Adesanya AA. An appraisal of the presentation and management of adult intussusception at a Nigerian Tertiary Hospital.Niger Postgrad Med J 2019;26:169-173


How to cite this URL:
Balogun OS, Olajide TO, Afolayan M, Lawal A, Osinowo AO, Adesanya AA. An appraisal of the presentation and management of adult intussusception at a Nigerian Tertiary Hospital. Niger Postgrad Med J [serial online] 2019 [cited 2019 Aug 25 ];26:169-173
Available from: http://www.npmj.org/text.asp?2019/26/3/169/264386


Full Text

 Introduction



Intussusception is defined as an invagination of a proximal segment of bowel (intussusceptum) and its associated mesentery into the lumen of an adjacent distal bowel segment (intussuscipiens).[1] It is an important cause of abdominal pain requiring surgical intervention in children and adults. Compared to paediatric intussusception, adult intussusception is considered uncommon, representing 5% of all cases of intussusception and 1%–5% of cases of intestinal obstruction in adults.[1] About 95% of paediatric intussusception have no known cause, while specific aetiology can be demonstrated in up to 80%–90% of adult intussusception.[2],[3]

Etiologically, adult intussusception can be classified into benign, malignant or idiopathic types. There are also enteric (small bowel) and colonic forms which have been sub-classified into four categories (entero-enteric, colo-colonic, ileo-colonic and ileo-caecal) depending on the location and the segment of bowel involved in the pathology.[4] Varieties of benign and malignant lesions have been found to be associated with adult intussusception. These lesions include submucosal lipoma, intestinal polyps, Meckel's diverticulum and lymphoma.[3],[4] These mural lesions are believed to cause an alteration in the normal motility of the gastrointestinal tract with the formation of specific 'lead points'. These lead points act as 'initiators' of the invagination process leading to bowel obstruction or gastrointestinal bleeding.[5],[6]

Clinical presentation of adult intussusception can be acute, subacute or chronic.[7] Delay in diagnosis and presentation may occur in the subacute and chronic types as the pattern of abdominal pain is non-specific, recurrent, less in severity and resolves within a short time.[7],[8] However, abdominal ultrasound and computed tomography (CT) scans of the abdomen may aid early diagnosis. Surgery is regarded as the mainstay of treatment of adult intussusception. Surgical options include en bloc resection of the intussusception and primary anastomosis, manual reduction at surgery followed by a more limited bowel resection and the less commonly used simple manual reduction without resection.[8]

A study done at our institution over 30 years ago, examined the etiopathological features and management outcome of adult intussusception.[9] Eleven adult intussusception cases were reported over a 12-year period.[9] We had continued to encounter adult intussusception at our surgical practice from time to time. More recently, the incidence of adult intussusception at our institution appears to be increasing. This study was done to review and document the pattern of presentation, clinicopathological features and surgical management of adult intussusception at our institution during the past 10 years. We also observed the occurring trends of this lesion.

 Patients and Methods



This was a retrospective study of 20 consecutive patients 16 years and above, who had intussusception and were managed between July 2008 and June 2018 at the Lagos University Teaching Hospital, Idi-araba, Lagos, Nigeria. Information obtained from case notes and pathology records included age, gender, symptoms, duration of symptoms, signs, surgical treatment, aetiology of intussusception, pathological type, histology and outcome.

The diagnosis of Intussusception was based on intraoperative findings at laparotomy as depicted in [Figure 1]. The etiology of intussusception was determined by the histological diagnosis of the resected bowel segment. Patients with rectoanal intussusception from prolapse, which is a distinct clinical entity, were excluded from the study. The mode of presentation as calculated from the duration of symptoms was grouped into acute (duration less or equal to 3 days), subacute (4–14 days) and chronic (more than 14 days).[10] Based on the origin and bowel segment involved in intussusception, we classified various types of intussusception into enteric (jejunojejunal, jejuno-ileal and ileo-ileal), colonic (caeco-colic and colo-colic), ileo-caecal and ileo-colic intussusception.[4] Data analysis was done using IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY, USA: IBM Corp.{Figure 1}

 Results



Demography and clinical features

Of 20 adult patients, who had an exploratory laparotomy for adult intussusception during the study, there were 9 (45%) males and 11 (55%) females giving a ratio of 1–1.2. The age range of patients under consideration was 18–66 years with a mean of 45.7 years [Table 1].{Table 1}

Clinical features and intraoperative findings

Abdominal pain was the main complaint in 17 (85%) out of 20 patients. Abdominal distension was present in 16 (80%) patients, followed by vomiting in 14 (70%) patients. Rectal bleeding was recorded in 4 (20%) patients. Two patients (10%) reported weight loss. The duration of symptoms before presentation in hospital ranged from 1 to 90 days. Palpable abdominal mass at presentation was recorded in 7 of 20 (35%) patients [Table 2].{Table 2}

The mode of presentation was acute in 5 (25%), subacute in 7 (35%) and chronic in 8 (40%) patients, respectively [Table 2]. Fourteen (70%) out of 20 patients had clinical and radiological features of intestinal obstruction. Of this, perforation and gangrene were found in four patients at surgery. Enteric intussusception of the jejuno-ileal type was the most common pathologic variety in this study and was seen in 7 (35%) patients followed by colo-colic intussusception in 5 (25%) patients [Table 3].{Table 3}

Surgical treatment offered

Segmental bowel resection and end-to-end anastomosis was the surgical treatment offered to all patients except in two scenarios [Table 3]. The simple reduction was performed in a male patient with post-operative intussusception diagnosed at 5th day post-laparotomy. Another patient with gangrenous colo-colic intussusception had resection (subtotal colectomy) of intussusception with a terminal ileostomy. Primary anastomosis following resection was feasible in most patients in this study except in a patient who presented acutely with gangrenous edematous colo-colic intussusception complicated by septicaemia. In this patient, the resection of intussusception and terminal ileostomy was performed. Reversal of ileostomy was performed successfully after 6 months. The post-operative period was uneventful in most patients. There was no mortality in cases reviewed.

Histopathologic findings

The most common cause of intussusception in this series was idiopathic in 11 (55%) patients. Submucosal lipoma was the most common benign lesion identified in 3 (15%) bowel specimens of which two were located in the ileum and one in the colon. Malignant lesions were found in 2 (10%) patients in this study. Both were Non-Hodgkin's lymphomas (one enteric and one colonic) [Table 4].{Table 4}

 Discussion



The relative rarity of adult intussusception is supported by their documentation in literature as case reports and case series.[2],[8],[11],[12] Our report of 20 cases of adult intussusception in this study is most likely one of the largest series from Nigeria. An important finding of our study is that the number of cases of adult intussusception seen at our institution during a 10-year period was almost twice that recorded in a 12-year review by Ademiluyi more than 30 years ago.[9] This trend may be attributed partly to the surge in population of Lagos over the past three decades. In addition, increased use of modern imaging facilities has enabled early and more specific diagnosis of intussusception in patients with abdominal complaints. In contrast to our finding, a study done two decades ago at Ibadan had reported declining cases of adult intussusception.[13] The reason behind the observed decline was not stated in the study. About the same time, Irabor et al. and Nmadu observed a reduction in the number of cases of caeco-colic intussusception and an increase of the ileocolic type.[14],[15]

The gender distribution of patients in this study showed a slightly higher preponderance of adult intussusception in females with a male-to-female ratio of 1:1.2. This pattern was similar to that reported previously by Ademiluyi in Lagos and Udo in Uyo, Nigeria.[9],[16] Conversely, a retrospective review of adult intussusception by Ugwu et al.[17] in Jos reported a higher prevalence in males with a male-to-female ratio of 1:1.4. While few studies on adult intussusception[18],[19],[20] had reported equal gender distribution, different patterns of gender distribution as observed in our region and reported in most series may suggest that the risk of developing adult intussusception is not necessarily associated with patients' gender.

Clinical presentation of adult intussusception varies. The onset of symptoms of adult intussusception is usually insidious, intermittent rather than acute. Almost all patients in Ademiluyi's series had delayed presentation with duration of symptoms of 4 weeks and more. Adult intussusception has no characteristic symptom and no pathognomonic clinical signs.[21] Abdominal pain is the most common symptom and is often recurrent and self-limiting. This may explain the delay in presentation and diagnosis in most cases. Other less common and nonspecific symptoms include abdominal distension nausea and vomiting, alteration in bowel habit and lower gastrointestinal bleeding.[1],[5],[21],[22] The characteristic red-currant jelly stool of paediatric intussusception is not common in adult intussusception.[23] Abdominal pain being the most common symptoms in our patients was in consonance with most documented reports on adult intussusception.

Abdominal mass on palpation has been reported in 24%–42% of adult intussusception. This mass has been described as 'shifting mass' or palpable mass when symptoms are present. They are usually not distinguishable from other intra-abdominal neoplasms.[23] Seven (35%) patients in this study had clinically palpable abdominal mass at presentation. Symptoms suggestive of malignancy such as rectal bleeding and weight loss were found in the minority of patients in this study.

Plain abdominal X-ray may show features of acute small or large bowel obstruction in adult intussusception but has no specific sign for intussusception. Abdominal ultrasound is the first line of radiologic investigation in paediatric intussusception with overall sensitivity of 97.9% whereas in adult intussusception, both abdominal ultrasound and CT scan have similar sensitivity ranging from 58% to 100%.[5],[24] There are major limitations of abdominal ultrasound which include operator dependency and masking of the lesion by obese body habitus and bowel loop gases in obstruction.[5],[24] The characteristic diagnostic features on intussusception of CT scan include heterogeneous 'target' or 'sausage-shaped' soft-tissue mass consisting of an outer intussuscipiens and central intussusceptum (bowel in bowel) [Figure 2]. Mesenteric fat and vessels may be visualised within the bowel lumen, and there may be varying degrees of proximal bowel dilatation.[25],[26]{Figure 2}

In the paediatric age groups, hydrostatic reduction of intussusception under fluoroscopy is a well-established treatment procedure.[27] Operative reduction is also widely used.[28] This is due to low risk of malignancy in paediatric intussusception.[27],[28] However, it is debatable if operative reduction alone has an equivalent level of safety in adults.[28] Simple operative reduction of adult intussusception is rarely indicated and except in proven cases of benign conditions, absence of ischaemia, strangulation and in recurrent intussusception where multiple bowel resections will cause short bowel syndrome.[29],[30] In this series, the only patient who had simple operative reduction developed post-operative intussusception following sigmoid colectomy for volvulus at 5th day post-surgery. We found a mural wall haematoma on the jejunal wall in this patient at second surgery.

Other surgical options for adult intussusception include en bloc resection without reduction and reduction followed by resection.[30] The choice of treatment in the last two scenarios has remained a controversial issue amongst surgeons. Advocates of en bloc resection without reduction are of the opinion that bowel manipulation at the reduction of intussusception can theoretically lead to tumour implantation, bowel ischaemia, perforation and microbial contamination of the peritoneal cavity.[1],[12],[31] In some authors opinion, there appears to be lack of large scale studies in the literature to validate these claims. In some series, en bloc bowel resection was recommended as the first option for colonic adult intussusception due to a high risk of associated malignancy.[31] Hence, operative reduction followed by resection was advised for some selected cases of enteric adult intussusception where there is a need to conserve bowel length, and malignancy can be ruled out.[32]

We are in support of the opinion that bowel resection should be the standard of care for most cases of adult intussusception because it will specifically treat the lesion if it is mitotic. More so, some authorities believe there may be difficulty in distinguishing benign from malignant causes with imaging preoperatively and even during surgery. In addition, some documented indications for operative reduction such as inflammatory bowel disease are relatively uncommon in our environment.[33] Facilities to follow-up of these patients are also greatly limited.

At surgery, entero-enteric intussusception predominantly jejuno-ileal variety was the most common type seen. Other types (ileo-ileal, ileo-caecal and ileo-colic) were found to the same degree. Ademiluyi recorded ileo-ileal variety in 3 out 11 patients and ileocolic in 2 out of 11 patients. There was no recorded case of jejuno-ileal intussusception in his series. In Ibadan, caeco-colic intussusception reported decades ago by Elebute and Adesola[34] and later dismissed as a 'myth' by Irabor et al.[14] were absent in our study. In addition, there was no recorded case of jejuno-jejunal intussusception in our patients. The reason for these disparities is that it seems there are no standard ways of reporting exact types of intussusception and accurate intraoperative diagnosis may be affected by subjective interpretation by different operating surgeons.

Overall, we found idiopathic aetiology in 55% of our patients versus 45% by Ademiluyi's series. Idiopathic intussusception was the most common histopathological diagnosis in the two series. However, submucosal lipoma accounted for the majority (15%) of benign cases in our review. Benign intussusception from infective conditions (tuberculous granuloma) as reported by Ademiluyi was not seen in any of our patients. There was low incidence of mitotic lesions which were found in only 2 (10%) out of 20 patients in this study. These findings further affirm the relative paucity of mitotic lesions associated with adult intussusception. Similar findings have been documented in many larger scale reports in the literature. There was no mortality recorded in the review though we had no follow-up information in those patients with a histologic diagnosis of malignancy who were referred to the medical oncologist.

The major limitations of this study are its retrospective nature and the small sample size. Although adult intussusception is considered a rare clinical entity; studies with a larger sample size than the one we have reported will be needed to further validate some of our inferences.

 Conclusion



Adult intussusception is considered an unusual cause of abdominal pain with delayed presentation. Compared to the documented findings of 3 decades ago, more cases of adult intussusception were seen in the past 10 years. The predominant aetiology for adult intussusception in our setting remains unknown. Even though few cases of adult intussusception in this study are due to malignancies, bowel resection and primary anastomosis are recommended in most cases of adult intussusception for optimal treatment. A simple manual reduction may however suffice in some selected cases of post-operative intussusception.

There are conflicts of interest.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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