CT Abdomen/Pelvis with IV and oral contrast. 

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... the clinical diagnosis can be challenging in adults. The etiology of adult intussusception can be due to idiopathic, benign, or malignant processes [3]. There are many publications in the literature about intestinal intussusceptions of various identifiable etiologies, however, there are only a few publications commenting on idiopathic intestinal intussusceptions. In this paper, four cases of entero-enteric intussusceptions are presented, with three of them idiopathic in etiology and one associated with a jejunal carcinoid tumor. While surgical treatment was once argued to be universally appropriate for adult intussusceptions, recent literature suggests that a more selective approach is warranted. Our aim is to raise awareness to the potential diagnosis and management of intussusceptions, particularly the symptomatic idiopathic type in the young adult. A 20-year-old man presented to the emergency department (ED) after a motor vehicle accident with soft tissue contusions, several abrasions, and abdominal pain. The abdominal pain, however, was not associated with the trauma, as he developed a colicky abdominal pain two days prior to his presentation. During this time he also complained of loss of appetite, diarrhea, and one episode of nausea and vomiting. His vital signs were within normal physio- logical range. His physical exam revealed a soft, non-tender, and non-distended abdomen, a normal rectal exam, and no signs of obstruction or peritonitis. CT scan of his abdomen and pelvis with and without IV contrast revealed a 3 cm long intussusception of the small bowel without obstruction (Fig. 1 ) . CBC, CMP, and urine analysis were all within normal limits. The patient was admitted for clinical follow up with a conservative approach. Serial abdominal examinations were performed. Further radiographic testing with a small bowel series was undertaken to restudy the intussusception which showed resolution and no other pathology. Based on the clinical picture and radiographic findings, a diet was started and advanced as tolerated. He was discharged later that day. At the time of writing, the patient is without any signs or symptoms of recurrence. An 18-year-old man presented to the ED complaining of left upper quadrant abdominal pain. Physical exam, labs, and CT of the abdomen and pelvis were normal. Without any concerning findings, the patient was discharged. Three days later, the patient returned to the emergency department, describing intermittent left upper quadrant abdominal pain without any episodes of nausea, vomiting, fevers, chills, hematochezia, melena, diarrhea, or consti- pation. Vital signs were all within normal limits. His abdomen was soft and non-distended, however the left upper quadrant was tender to touch without peritoneal signs. His labs were within normal limits. The CT of the abdomen and pelvis revealed a jejuno-jejunal intussusception with a length of 2.9 cm in the left upper quadrant (Fig. 2). No bowel obstruction was found. The patient was admitted for observation with serial abdominal exams and conservative management. Resolution of the jejuno-jejunal intussusception was documented on repeat CT. His symptoms improved clinically and his exam findings and vital signs remained normal. He was subsequently discharged. Three months later, the patient again presented to the ED with a half-day history of vague abdominal pain localized to the umbilicus and associated nausea. According to the patient, the pain was similar to the pain from his previous presentation. Vital signs were all within normal limits. The abdominal exam was benign, without peritoneal signs. CT of the abdomen and pelvis revealed an intussusception, but this time at the level the umbilicus in the anterior abdomen, again without associated obstruction (Fig. 3). Labs revealed no abnormalities. The patient was admitted for observation with conservative management. Repeat CT of the abdomen and pelvis showed persistence of the intussusception, with a measured length of about 1.5 cm. A second focus of intussusceptions was also found inferior to the formerly described intussusception and slightly to the left of midline, which was measured to be about 2.2 cm without obstruction. He reported his pain to be less severe. Physical exam, vitals, and labs were normal. Subsequent small bowel follow-through studies revealed resolution of the intussusceptions. The patient’s clinical status continued to improve, so he was discharged. He has had no recurrences to this date. A 19-year-old woman presented to the ED with pain localized to the mid/right upper abdomen, nausea, and a low grade temper- ature for approximately 2 weeks. The abdomen was found to be soft, non-distended, and tender in the right upper quadrant without peritoneal signs. All vital signs and labs were normal. CT of the abdomen and pelvis with IV and oral contrast revealed an intussusception with a length of 2.7 cm in the right upper quadrant without any signs of obstruction (Fig. 4). She was kept overnight and followed with conservative management. A repeat CT of the abdomen and pelvis with oral contrast revealed resolution of the intussusception. The patient’s pain resolved and her exam findings remained normal. Discharge ensued and she has not been back with similar symptoms since the previous admission. A 34-year-old woman with sudden onset of generalized abdominal tenderness was transferred from an outside hospital. Her history was significant for multiple prior admissions for abdominal problems, the first of which was for an ischemic bowel in 2005, which was treated with an ileo-colic anastomosis. In 2013, she presented with severe anemia and EGD revealed a carcinoid tumor in the lesser curvature of her stomach which was removed endoscopically. She presented again in 2013, shortly before her current admission, and CT scan revealed two nodules in the liver, a nodule in the left adrenal gland, and an umbilical hernia. Her liver nodules were concerning for carcinoid syndrome, but urine 5-HIAA at this time was negative. Her history was also significant for volvulus, multiple gastric ulcers, and a tubular adenoma found on colonoscopy. When she arrived to our hospital in August of 2013, her physical exam was significant for diffuse abdominal tenderness. She reported that her last bowel movement was earlier on the day of admission. An abdominal CT was ordered, which showed multiple dilated loops of bowel and three distinct target signs (Fig. 5), as well as significant mechanical traction of the distal small bowel. The patient was taken to the operating room for an exploratory laparotomy. A midline incision was made and an intussusception was visualized affecting the proximal jejunum (Fig. 6). A carcinoid tumor was identified which served as the lead point for the intussusception. The affected portion of bowel was resected, and a jejunojejunal anastomosis was created. An area of narrowed ileum was discovered near the ileocolic anastomosis previously created after her episode of ischemic bowel. Mesenteric foreshortening was noted throughout the bowel as were multiple fibrotic implants. An internal hernia and an umbilical hernia were noted, though they did not appear to act as lead points, and subsequently reduced. The patient had no apparent complications from the procedure and recovered well. She was discharged on post-operative day 8 and was followed up in clinic as an outpatient. The etiology, clinical features, and management of intussusception differ markedly between adults and children. Intussusceptions are much more common in children, with adults accounting for about 5% of all cases [2]. It is the most common cause of bowel obstruction in children, whereas it is responsible for only about 1% of cases in adults [1,5]. Pediatric cases classically present with a triad of acute onset of abdominal pain, currant jelly stools, and a palpable sausage-like mass in the abdomen, while adults tend to have more chronic and nonspecific symptoms suggestive of par- tial obstruction [1,2]. Cases in children are idiopathic 90% of the time, where the lead point is thought to be caused by lymphoid hyperplasia after a preceding viral infection [1]. In contrast, adult intussusceptions are less likely to be idiopathic and more likely to be associated with a malignancy [2,3,6]. Many processes can act as lead points in adults, not limited to polyps, benign neoplasms such as lipomas, colonic divertic- ula, Meckel’s diverticulum, strictures, feeding tubes, and malignant neoplasms of the bowel [2,7–10]. Common locations of intussusceptions in adults involve the intestinal segments lying between the freely moving bowel loops and attachments of any kind, such as the anatomical attachments to the retroperitoneum or bowel segments tethered by adhesions [2,11]. Entero-enteric intussusceptions account for the majority of cases in adults, though gastro-enteric, ileo-colic, and colo-colonic intussusceptions also occur [12,13]. In our patient population, all intussusceptions were entero-enteric. One case was caused by a carcinoid tumor in the proximal jejunum while three were transient and idiopathic in nature, with initial and follow up studies that did not demonstrate or suggest a suspicious lead point. Furthermore, none of the three patients with transient intussusception had any previous surgical history, thus eliminating adhesions as a potential contributor to their disease. The presentation of adult intussusception is highly variable, making diagnosis in the adult patient difficult. Intussusception involves the telescoping of a segment of bowel, along with its mesentery, into an adjacent segment. If venous blood flow is compromised, the tissue can become edematous, ischemic, and eventually necrotic. Frequently, patients will complain of vague, chronic, and nonspecific symptoms. Pain seems to be the most common symptom, being present in 71–90% of adult patients [3,14]. Nonspecific symptoms in adults ...