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Peering Into Ileocolic Intussusception: A Radiological Exploration
Authors: Andres Hernan Vejarano Galvis, Laura Lopez Rodriguez, Alfonso Nahum Benitez Calvo, Maria Fraga Sanchez
1Clinical History
84-year-old woman presented to the emergency department with 24 hours of severe abdominal pain and diarrhea, without febrile syndrome. Reports an 8 kg weight loss over the past year with no other relevant medical history. On physical examination, deep palpation tenderness in the right iliac fossa, otherwise unremarkable. Complete blood count within normal limits, with no elevation of acute-phase reactants or biochemical abnormalities.
2Image Findings
Abdominal ultrasound was performed using a Canon Aplio i800 system with an i8CX1 probe. A systematic abdominal ultrasound was initially conducted, followed by a targeted examination guided by the patient. A well-defined, lobulated lesion measuring approximately 11 × 6 cm (AP × T) was identified in the right iliac fossa (Fig.1).
On longitudinal imaging, alternating layers of bowel were observed, demonstrating the "sandwich sign" (Fig.2). Transverse views revealed focal areas of bowel wall thickening with increased vascularity (Fig.3). At certain angles, the longitudinal images appeared as an elongated mass with alternating echogenic layers, resembling the 'pseudokidney sign,' highlighting the importance of multiplanar evaluation.
Given the suspicion of intestinal intussusception, an abdominal CT scan with IV contrast in the parenchymal phase was performed, which better characterized the thickening at the base of the intussusception, suggesting a probable lead point (Fig.4).
On longitudinal imaging, alternating layers of bowel were observed, demonstrating the "sandwich sign" (Fig.2). Transverse views revealed focal areas of bowel wall thickening with increased vascularity (Fig.3). At certain angles, the longitudinal images appeared as an elongated mass with alternating echogenic layers, resembling the 'pseudokidney sign,' highlighting the importance of multiplanar evaluation.
Given the suspicion of intestinal intussusception, an abdominal CT scan with IV contrast in the parenchymal phase was performed, which better characterized the thickening at the base of the intussusception, suggesting a probable lead point (Fig.4).
3Diagnosis
Ileocolic intussusception with a probable lead point.
4Discussion
BACKGROUND:
Intestinal intussusception in older adults is rare and often linked to an underlying pathology, most commonly malignancies. In the ileocolic region, up to 93.8% of cases are associated with tumors, 80% of which are malignant [1]. Unlike in children, where intussusception is usually idiopathic and presents acutely, adult cases often have an insidious onset with abdominal pain, weight loss, and bowel habit changes [2]. CT is the preferred imaging modality due to its high sensitivity and ability to identify a lead point, but ultrasound remains valuable, especially in initial evaluations [2].
Sonographically, intussusception appears as a layered mass with alternating echogenicity, producing classic signs such as the "target" or "donut" sign in transverse views and the "sandwich" or "pseudo-kidney" sign in longitudinal views [1,2]. However, in adults, the "donut" sign is less frequent and often distorted due to tumor-related changes [1]. Bowel wall thickening and overall lesion size are significantly greater than in children, reflecting neoplastic involvement [3]. Mesenteric lymphadenopathy is also less common in adults, whereas it is a frequent finding in pediatric ileocolic intussusception [4]. Recognizing these sonographic differences is crucial for early suspicion, guiding further imaging with CT, and differentiating intussusception from other bowel pathologies with overlapping presentations.
CLINICAL PERSPECTIVE:
In adult ileocolic intussusception with suspected malignancy, surgical resection without prior reduction is standard to prevent tumor dissemination. Right hemicolectomy is typically indicated, ensuring oncologic integrity. However, given the patient’s advanced age and significant weight loss, the oncologic stage remains uncertain. If the malignancy is advanced, surgery may not provide a meaningful survival benefit, exposing the patient to perioperative risks without improving prognosis.
THERAPY PLANNING:
In this case, CT allowed for local staging, and a chest X-ray ruled out the primary site of distant metastasis. Given the presence of acute obstruction, the patient underwent urgent surgery. The imaging findings played a crucial role in guiding management, confirming the need for immediate intervention while ensuring an appropriate oncologic assessment.
OUTCOME & PROGNOSIS:
The patient underwent a successful right hemicolectomy with ileocolic anastomosis due to ileocolic intussusception causing acute obstruction. Histopathological analysis confirmed adenocarcinoma with clean surgical margins. The immediate prognosis is favorable, with resolution of the acute obstruction. Given the clear margins, further oncological follow-up is recommended to assess for recurrence or metastasis. Radiological monitoring will be essential for early detection of any signs of recurrence.
Intestinal intussusception in older adults is rare and often linked to an underlying pathology, most commonly malignancies. In the ileocolic region, up to 93.8% of cases are associated with tumors, 80% of which are malignant [1]. Unlike in children, where intussusception is usually idiopathic and presents acutely, adult cases often have an insidious onset with abdominal pain, weight loss, and bowel habit changes [2]. CT is the preferred imaging modality due to its high sensitivity and ability to identify a lead point, but ultrasound remains valuable, especially in initial evaluations [2].
Sonographically, intussusception appears as a layered mass with alternating echogenicity, producing classic signs such as the "target" or "donut" sign in transverse views and the "sandwich" or "pseudo-kidney" sign in longitudinal views [1,2]. However, in adults, the "donut" sign is less frequent and often distorted due to tumor-related changes [1]. Bowel wall thickening and overall lesion size are significantly greater than in children, reflecting neoplastic involvement [3]. Mesenteric lymphadenopathy is also less common in adults, whereas it is a frequent finding in pediatric ileocolic intussusception [4]. Recognizing these sonographic differences is crucial for early suspicion, guiding further imaging with CT, and differentiating intussusception from other bowel pathologies with overlapping presentations.
CLINICAL PERSPECTIVE:
In adult ileocolic intussusception with suspected malignancy, surgical resection without prior reduction is standard to prevent tumor dissemination. Right hemicolectomy is typically indicated, ensuring oncologic integrity. However, given the patient’s advanced age and significant weight loss, the oncologic stage remains uncertain. If the malignancy is advanced, surgery may not provide a meaningful survival benefit, exposing the patient to perioperative risks without improving prognosis.
THERAPY PLANNING:
In this case, CT allowed for local staging, and a chest X-ray ruled out the primary site of distant metastasis. Given the presence of acute obstruction, the patient underwent urgent surgery. The imaging findings played a crucial role in guiding management, confirming the need for immediate intervention while ensuring an appropriate oncologic assessment.
OUTCOME & PROGNOSIS:
The patient underwent a successful right hemicolectomy with ileocolic anastomosis due to ileocolic intussusception causing acute obstruction. Histopathological analysis confirmed adenocarcinoma with clean surgical margins. The immediate prognosis is favorable, with resolution of the acute obstruction. Given the clear margins, further oncological follow-up is recommended to assess for recurrence or metastasis. Radiological monitoring will be essential for early detection of any signs of recurrence.
5Teaching Points
When intussusception is suspected in adults, particularly in the ileocolic region, consider the possibility of an underlying malignancy. Neoplastic causes often lead to greater bowel wall thickening, larger lesion size, and altered imaging characteristics compared to benign cases, which are typically smaller and more uniform.
6References
[1.] Honjo H, Mike M, Kusanagi H, Kano N. Adult intussusception: a retrospective review. World J Surg 2015; 39(1): 134-138.
[2.] Chand J, R R, Ganesh MS. Adult intussusception: a systematic review of current literature. Langenbecks Arch Surg 2024; 409(1): 235.
[3.] Park NH, Park SI, Park CS, et al. Ultrasonographic findings of small bowel intussusception, focusing on differentiation from ileocolic intussusception. Br J Radiol 2007; 80(958): 798-802.
[4.] Subramaniam S, Chen AE, Khwaja A, Rempell R. Point-of-care ultrasound for differentiating ileocolic from small bowel-small bowel intussusception. J Emerg Med 2022; 62(1): 72-82.
[2.] Chand J, R R, Ganesh MS. Adult intussusception: a systematic review of current literature. Langenbecks Arch Surg 2024; 409(1): 235.
[3.] Park NH, Park SI, Park CS, et al. Ultrasonographic findings of small bowel intussusception, focusing on differentiation from ileocolic intussusception. Br J Radiol 2007; 80(958): 798-802.
[4.] Subramaniam S, Chen AE, Khwaja A, Rempell R. Point-of-care ultrasound for differentiating ileocolic from small bowel-small bowel intussusception. J Emerg Med 2022; 62(1): 72-82.
