Adult Intestinal Intussusception

Adult Intestinal Intussusception:
CT Appearances and Identification

of a Causative Lead Point
Young H. Kim, Michael A. Blake, Mukesh G. Harisinghani,
Krystal Archer-Arroyo, Peter F. Hahn, Martha B. Pitman, Peter
R. Mueller
Author Affiliations
Published Online:May 1 2006https://doi.org/10.1148/rg.263055100
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Abstract
The widespread application of computed tomography (CT) in different
clinical situations has increased the detection of intussusception,
particularly non–lead point intussusception, which tends to be
transient. Consequently, determining the clinical significance of
intussusception seen at CT poses a diagnostic challenge. Patients
with intussusception may or may not be symptomatic, and symptoms
can be acute, intermittent, or chronic, making clinical diagnosis
difficult. In most cases, radiologists can readily make the correct
diagnosis of intestinal intussusception by noting the typical bowel-
within-bowel appearance at abdominal CT. However, the CT findings
that help differentiate between lead point and non–lead point
intussusception have not been well studied. Nevertheless, although
there is considerable overlap of CT findings, when a lead mass is
seen at CT as a separate and distinct entity vis-à-vis edematous
bowel, it can be considered a reliable indicator of a lead point
intussusception. Differentiating between lead point and non–lead
point intussusception is important in determining the appropriate
treatment and has the potential to reduce the prevalence of
unnecessary surgery.
© RSNA, 2006
LEARNING OBJECTIVES FOR TEST 2
After reading this article and taking the test, the reader will be able to:
• Describe the CT appearances of adult intestinal intussusception.

.
• List the clinical manifestations of adult intestinal intussusception.

.
• Discuss the CT findings that can help differentiate between intussusception w

. intussusception without a lead point.
Introduction
Approximately 5% of all intussusceptions occur in adults, accounting
for 1% of all bowel obstructions (,1). It has often been stated that
intestinal intussusception in adults is frequently caused by serious
underlying disease, with 70%–90% of cases having a demonstrable
cause based on discharge diagnosis or surgical results (,1,,2). The
growing use of computed tomography (CT) for abdominal imaging
has led to increased detection of transient intussusceptions with no
underlying disease. Consequently, determining the clinical
significance of intussusception detected with CT poses a fresh
diagnostic challenge. In this article, we review the pathophysiologic
features and classification of intussusception. We also discuss and
illustrate the clinical and CT manifestations of lead point versus non–
lead point intussusceptions and of small bowel versus large bowel
intussusceptions.
Pathophysiologic Features of
Intussusception
Intussusception is the invagination of a bowel loop with its mesenteric
fold (intussusceptum) into the lumen of a contiguous portion of bowel
(intussuscipiens) as a result of peristalsis. Intraluminal polypoid
lesions have a greater tendency to cause invagination of the bowel as
peristalsis drags the lesion forward. Although the exact mechanism
precipitating intussusception, especially intussusception without a
lead point, is not well understood, this condition has been ascribed to
dysrhythmic contractions.
Classification of Intussusception
Intussusceptions are classified according to location (enteroenteric,
ileocolic, ileocecal, or colocolic) and cause (benign, malignant, or
idiopathic). Intussusception in an adult can be further classified on the
basis of whether a lead point is present (,Table 1).
Intussusception without a lead point tends to be transient. Although
an intussusception with a lead point tends to be persistent or
recurrent, it can also be transient. Transient nonobstructing
intussusception without a lead point is known to occur in both adults
and children and occurs more frequently than was previously
reported (,3–,5). Transient intussusception of the small bowel has
been reported in adults with celiac disease (,2) and Crohn disease
(,6) but is most frequently detected incidentally and is presumed to be
innocuous. On rare occasions, transient tumor-related colocolic
intussusception can occur (,7).
Manifestations of Intussusception
Intussusception without a Lead Point
Intussusception without a lead point may manifest as vague
abdominal pain; however, most cases are discovered incidentally at
CT performed for other reasons. An intussusception without a lead
point does not generally cause proximal bowel obstruction (,8). It
typically appears as a targetlike or sausage-shaped mass, depending
on the axial projection (,9). Distinct anatomic features, including the
entering wall, mesenteric fat and vessels, returning wall, and
intraluminal space, can be clearly seen at CT (,Figs 1, ,2). At
abdominal CT, the presence of a bowel-within-bowel configuration
with or without mesenteric fat and mesenteric vessels is
pathognomonic for intussusception (,Fig 3,,).
Intussusception with a Lead Point

Intussusception with a lead point may manifest with atypical clinical
findings. Often, there is a prior history of episodic crampy abdominal
pain, nausea, and vomiting, symptoms that suggest partial intestinal
obstruction (,9,,10). Intussusception with a lead point can also
manifest with symptoms related to a neoplastic process, including
constipation, weight loss, melena, or a palpable abdominal mass at
physical examination, rather than specific symptoms related to the
intussusception itself. Symptomatic diagnosis of intussusception with
a lead point is difficult owing to the variety of clinical manifestations.
The presence of a lead point, the configuration of the lead mass, the
degree of bowel wall edema, and the amount of invaginated
mesenteric fat all affect the appearance of an intussusception. If there
is bowel wall edema due to impaired circulation of the mesenteric
vessels, thickened bowel loops make it difficult to differentiate a lead
mass from inflammation because the former may appear amorphous
(,Fig 4,). An intussusception with a lead point appears as an abnormal
targetlike mass with a cross-sectional diameter greater than that of
the normal bowel and may be associated with proximal bowel
obstruction. Identification of a lead mass that is separate and distinct
from bowel loops is not easy; however, a mass that is seen at CT can
serve as a reliable radiologic indicator of an intussusception with a
lead point, even though it is hard to discern the exact underlying
disease in most cases. Identification of distinct anatomic features is
often challenging due to the complex appearance of both bowel wall
edema and the lead mass (,Fig 5).
The follow-up of incidentally detected intussusceptions with no known
underlying cause has not been clearly defined, and the respective
roles of modalities such as interval CT, small bowel follow-through
examination, enteroclysis, CT enteroclysis, and wireless capsule
endoscopy have yet to be determined (,11).
Small Bowel Intussusception

Small bowel intusssuception without a lead point is more common
than intussusception with a lead point (,3). Intussusception without a
lead point is known to appear as a nonobstructing segment, usually
smaller in diameter and shorter than an intussusception with a lead
point (,3,,12,,13). A lead point intussusception involving the small
bowel is generally due to a benign condition and less often to a
neoplasm, which, when it occurs, is usually a metastatic lesion (,10).
Such an intussusception involving the colon in an adult is often
related to a primary or secondary malignant neoplasm (,Table 2). If
there are findings suggestive of a lead point intussusception (eg, a
long, large-caliber segment with proximal bowel obstruction) and a
probable identifiable lead mass, surgical treatment should be
recommended.
Meckel Diverticulum
Meckel diverticulum is the most common congenital anomaly of the
gastrointestinal tract, occurring in 2%–3% of the population. Common
complications include hemorrhage, small bowel obstruction, and
diverticulitis. A Meckel diverticulum may invaginate or invert into the
lumen of the small intestine. Once inverted, the diverticulum may
serve as a lead point for an ileoileal or ileocolic intussusception (,Fig
6,,) (,14). Typically, an inverted Meckel diverticulum appears at CT as
a central core of fat attenuation surrounded by a collar of soft-tissue
attenuation. Provided this typical appearance is recognized at CT, the
diagnosis can be made prospectively (,15).
Venous Malformations
Venous malformations of the gastrointestinal tract may manifest with
bleeding, with anemia, or, if they form a mass, with intussusception
(,Fig 7,,,) (,16). The cecum is the most common site of venous
malformations, followed by the right colon and the jejunum. Patients
with venous malformations tend to be elderly with a history of
cardiovascular disease. In younger patients, venous malformations
tend to occur at atypical sites such as the small bowel (,17).
Inflammatory Fibroid Polyp

An inflammatory fibroid polyp of the gastrointestinal tract is a rare
polypoid lesion in this location. It is a type of inflammatory
pseudotumor or myo-fibroblastic tumor that occurs most commonly in
the stomach, followed by the small bowel, but it can be seen
throughout the gastrointestinal tract (,Fig 8,) (,18,,19). Inflammatory
fibroid polyp has been shown to ulcerate and cause gastrointestinal
bleeding and simple mechanical obstruction but rarely manifests with
intussusception (,19).
Lymphoma
Primary lymphoma of the gastrointestinal tract accounts for
approximately 20%–40% of all malignant tumors in the small bowel
(,20,,21). Common presenting symptoms include abdominal pain,
weight loss, small bowel obstruction, and acute abdomen. Most T-cell
lymphomas manifest as ulcerated plaques or strictures in the
proximal small bowel, whereas B-cell lymphomas tend to manifest as
annular or polypoid masses in the distal and terminal ileum (,21). CT
is increasingly being used for the evaluation of patients with known or
suspected gastrointestinal lymphoma, since it allows evaluation of
both the mural and extramural components of the disease. CT
findings of regional or mesenteric lymphadenopathy associated with a
bowel wall mass can help distinguish lymphoma from other bowel
diseases. When CT demonstrates mild bowel wall thickening with
small lymph nodes, the detection of the underlying cause of
intussusception may be difficult because differentiation from bowel
wall edema may not be possible (,Fig 9,,).
Metastatic Malignant Fibrous Histiocytoma

Malignant fibrous histiocytoma is the most common soft-tissue
sarcoma late in life, occurring most commonly in the extremities,
trunk, and retroperitoneum and rarely in the visceral organs (,22,,23).
Metastatic malignant fibrous histiocytoma can be an unusual cause of
small bowel intussusception when it manifests as a polypoid mass
(,Fig 10,,,).
Large Bowel Intussusception

More than one-half of large bowel intussusceptions are associated
with malignant lesions, including primary tumors (adenocarcinoma,
lymphoma) and metastatic disease (,1). Associated benign lesions
include neoplasms such as lipoma and adenomatous polyp (,8).
Colonic intussusception often manifests with abdominal pain due to a
recurring intussusception that causes intestinal obstruction (,8).
Identification of a lead mass at CT is often possible, although
determination of an underlying cause is not easy except in the case
of a lipoma, which manifests as a well-marginated mass with fat
attenuation. Transient tumor-related colocolic intussusception has
been reported (,7).
Ileocolic-Ileocecal Intussusception
Melanoma metastases to the gastrointestinal tract are the most
common metastatic lesions of the bowel (,Fig 11,,). Small bowel
metastases attributed to cutaneous malignant melanoma are found in
2%–5% of patients, with the small bowel being the most frequently
involved anatomic structure, followed by the stomach and large
bowel. Intussusception caused by metastatic melanoma is very rare
(,24). Patients who present with acute complications such as
bleeding, perforation, intussusception, and obstruction require urgent
surgical intervention (,25).
Colocolic Intussusception
Lipoma.—
Lipomas are the most common benign cause of colocolic
intussusception in adults. Next to adenomatous polyps, these
mesenchymal tumors are the most common benign tumors of the
colon. Lipomas of the colon are within the submucosa in 90% of
cases, are usually solitary, and may be sessile or pedunculated (,26).
Lipomas are often discovered incidentally at endoscopic or radiologic
examination and can easily be diagnosed with CT due to their typical
fat attenuation (,Fig 12). Close observation of consecutive axial
images can help avoid misinterpreting entrapped mesentery and
subserosal fat as a lipoma. Multiplanar reformation may be used to
confirm the diagnosis of intussusception when axial views raise
suspicion for such a diagnosis. Lipomas are almost always
asymptomatic until they cause abdominal pain, sometimes due to
intussusception.
Adenocarcinoma.—
Adenocarcinoma of the colon is the most common malignant
neoplasm associated with colonic intussusception (,Fig 13,). Typical
signs and symptoms of adenocarcinoma of the colon include
bleeding, obstruction, a palpable abdominal mass, and abdominal
pain. The individual layers of the intussuscepted bowel wall are more
easily distinguished from the lead mass in this intussusception.
Differentiation of the lead mass from bowel wall edema at CT is
generally easier in large bowel intussusception than in small bowel
intussusception due to the greater caliber of the colon.
Conclusions
Intussusceptions without a lead point are increasingly being identified
at routine CT and pose a diagnostic challenge.
Abdominal CT can be helpful in distinguishing between lead point
intussusception and non–lead point intussusception and has the
potential to reduce the prevalence of unnecessary surgery. Although
there is considerable overlap of CT findings, identification of a lead
mass that is separate and distinct from edematous bowel can help
make this distinction.
Table 1. Clinical Features of Adult Intestinal Intussusception
Table 2. Causes of Adult Intestinal Lead Point Intussusception

Figure 1. Longitudinal (top) and cross-sectional (bottom) diagrams
illustrate a typical transient type intussusception, with invagination of
a segment of the gastrointestinal tract (intussusceptum) (solid arrows)
into an adjacent segment (intussuscipiens) (open arrows). Note also
the invagination of the mesentery (M) and mesenteric vessels
(arrowheads). (Courtesy of B.I. Choi, MD, Department of Radiology,
Seoul National University Hospital, Seoul, South Korea.)
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Figure 2. Small bowel intussusception in a 51-year-old man with
recurrent left lower quadrant pain. Contrast material–enhanced CT
scan of the abdomen demonstrates the typical multilayered
appearance of a small bowel intussusception. The intussusceptum
(black arrowhead), with an accompanying complex of mesenteric fat
and blood vessels (arrow), is surrounded by the thick-walled
intussuscipiens (white arrowhead).
Figure 3a. Transient type small bowel intussusception in a 54-year-
old woman. Contrast-enhanced CT scans of the abdomen
demonstrate the classic findings of a targetlike (arrow in a), sausage-
shaped (arrow in b and c) mass, findings that are pathognomonic for
intussusception. Mesenteric fat and blood vessels are barely visible.
Figure 3b. Transient type small bowel intussusception in a 54-year-
Figure 3c. Transient type small bowel intussusception in a 54-year-
Figure 4a. Transient type small bowel intussusception in a 49-year-
old man with abdominal pain who had suffered a fall. (a) Contrast-
enhanced CT scan demonstrates an amorphous mass (arrow) that is
due to bowel wall edema, making differentiation difficult (cf ,Fig 9). (b)
Contrast-enhanced CT scan shows invaginated mesenteric fat and
vessels (arrowhead).
Figure 4b. Transient type small bowel intussusception in a 49-year-
old man with abdominal pain who had suffered a fall. (a) Contrast-
enhanced CT scan demonstrates an amorphous mass (arrow) that is
due to bowel wall edema, making differentiation difficult (cf ,Fig 9). (b)
Contrast-enhanced CT scan shows invaginated mesenteric fat and
vessels (arrowhead).
Figure 5. Longitudinal (top) and serial cross-sectional (bottom)
diagrams illustrate a lead point intussusception, with invagination of a
segment of the gastrointestinal tract (intussusceptum) into the
adjacent segment (intussuscipiens). Thick arrows indicate the lead
mass. The intussusceptum appears irregular due to bowel wall
edema. The classic three-layer appearance and anatomic detail are
often lost.
Figure 6a. Ileoileal intussusception in a 25-year-old man with right
lower quadrant pain. (a) Contrast-enhanced CT scan demonstrates
an ileoileal intussusception caused by an inverted Meckel
diverticulum (arrow). (b, c) CT scan (b) and photograph of the gross
surgical specimen (c) show the inverted Meckel diverticulum
(arrowheads in b, arrows in c). The typical fat attenuation
representing the inverted mesentery is not seen on the CT scan.
Figure 6b. Ileoileal intussusception in a 25-year-old man with right
Figure 6c. Ileoileal intussusception in a 25-year-old man with right
Figure 7a. Ileoileal intussusception in a 15-year-old girl with
recurrent abdominal pain, gastrointestinal bleeding, and anemia. (a,
b) Contrast-enhanced CT scans demonstrate an ileoileal
intussusception with multiple lead points (arrows). (c) Coronal
reformatted CT image demonstrates the entire intussusception
(arrowheads) and lead mass (arrow). (d) Photograph of the gross
specimen shows multiple venous malformations as lobulated masses
(arrows). Scale is in centimeters.
Figure 7b. Ileoileal intussusception in a 15-year-old girl with
Figure 7c. Ileoileal intussusception in a 15-year-old girl with
Figure 7d. Ileoileal intussusception in a 15-year-old girl with
Figure 8a. Ileoileal intussusception and small bowel obstruction
caused by an inflammatory fibroid polyp in the distal ileum in a 49-
year-old woman. (a) Contrast-enhanced CT scan demonstrates
invaginated mesenteric fat and vessels (arrow) as well as bowel wall
thickening of the intussusceptum and intussuscipiens that obscures
the lead mass (arrowhead). (b) Photograph of the gross specimen
shows a large (6-cm) pedunculated polypoid mass (arrow). Scale is in
centimeters.
Figure 8b. Ileoileal intussusception and small bowel obstruction
caused by an inflammatory fibroid polyp in the distal ileum in a 49-
year-old woman. (a) Contrast-enhanced CT scan demonstrates
invaginated mesenteric fat and vessels (arrow) as well as bowel wall
thickening of the intussusceptum and intussuscipiens that obscures
the lead mass (arrowhead). (b) Photograph of the gross specimen
shows a large (6-cm) pedunculated polypoid mass (arrow). Scale is in
centimeters.
Figure 9a. Intussusception in a 71-year-old woman with abdominal
pain. Contrast-enhanced CT scans of the abdomen demonstrate an
intussusception (arrow in a and b) with a round soft-tissue mass
serving as a lead point (arrow in c). The mass is isoattenuating
relative to bowel wall edema, making differentiation difficult (cf ,Fig 4).
The patient was found to have metastatic large B-cell lymphoma of
the jejunum.
Figure 9b. Intussusception in a 71-year-old woman with abdominal
the jejunum.
Figure 9c. Intussusception in a 71-year-old woman with abdominal
the jejunum.
Figure 10a. Intussusception in a 66-year-old woman with a small
bowel obstruction caused by metastatic malignant fibrous
histiocytoma. (a, b) Contrast-enhanced CT scans of the abdomen
demonstrate a typical intussusception with a lead point (arrow) and
associated bowel wall thickening. (c) Contrast-enhanced CT scan
shows enhancement of the lead point (arrowheads), a finding that
facilitates its identification. (d) Photograph of the gross specimen
shows multiple nodules (arrow and arrowheads), the largest of which
(arrow) is a pedunculated polypoid mass measuring 5 cm. Scale is in
centimeters.
Figure 10b. Intussusception in a 66-year-old woman with a small
centimeters.
Figure 10c. Intussusception in a 66-year-old woman with a small
centimeters.
Figure 10d. Intussusception in a 66-year-old woman with a small
centimeters.
Figure 11a. Ileocolic intussusception in a 41-year-old man with
metastatic melanoma who presented with gastrointestinal bleeding.
(a, b) Contrast-enhanced CT scans demonstrate an ileocolic
intussusception. The tumor that serves as the lead point (arrows in a)
originates in the cecum. An intussusception (arrow in b) of the distal
ileum is seen extending into the ascending colon. (c) Photograph of
the gross specimen shows a large pedunculated polypoid mass
(arrow). Scale is in centimeters.
Figure 11b. Ileocolic intussusception in a 41-year-old man with
Figure 11c. Ileocolic intussusception in a 41-year-old man with
Figure 12. Colocolic intussusception secondary to lipoma in a 73-
year-old woman. Contrast-enhanced CT scan of the abdomen
demonstrates an intraluminal mass with fat attenuation (arrow).
Figure 13a. Colocolic intussusception secondary to adenocarcinoma
in an 83-year-old woman. Contrast-enhanced CT scans of the
abdomen demonstrate the classic findings of a lead point
intussusception (arrowheads) with invaginated mesenteric fat and
vessels (arrows).
Figure 13b. Colocolic intussusception secondary to adenocarcinoma
in an 83-year-old woman. Contrast-enhanced CT scans of the
abdomen demonstrate the classic findings of a lead point
intussusception (arrowheads) with invaginated mesenteric fat and
vessels (arrows).

Adult Intestinal Intussusception

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Adult Intestinal Intussusception:

CT Appearances and Identification

• Describe the CT appearances of adult intestinal intussusception.

• List the clinical manifestations of adult intestinal intussusception.

• Discuss the CT findings that can help differentiate between intussusception w

Intussusception with a Lead Point

Small Bowel Intussusception

Inflammatory Fibroid Polyp

Metastatic Malignant Fibrous Histiocytoma

Large Bowel Intussusception

Table 1. Clinical Features of Adult Intestinal Intussusception

Table 2. Causes of Adult Intestinal Lead Point Intussusception

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