Enteric intussusception in adults.

Dear Sirs, We read with great interest the recent article of C. Toso et al. [Swiss Med Wkly 2005;135:87–90] [1], in which the authors report on a group of patients managed for intussusception over a 17-year period and review the literature. We agree with their views on the importance of early surgical management, but disagree with the emphasis placed on the utility of computed tomography (CT) as the diagnostic instrument of choice. A 42-year-old man was recently admitted to our Surgical Department complaining of severe pain in the upper abdomen and with bile-tinged vomit. His past medical history was negative for medical diseases or previous interventions. Physical examination showed diffuse hyperperistalsis and abdominal tenderness, but no abdominal masses were detected. The laboratory findings appeared normal except for slight hypokalaemia and hyperglycaemia. Abdominal x-ray revealed only sparse air-fluid levels, while ultrasonography (US) and CT scan were not helpful in clarifying the diagnosis. A volvulus was suspected and the patient was preoperatively treated by nasogastric tube positioning, fluid resuscitation and antibiotic prophylaxis. Exploratory laparoscopy showed a 30 cm tract of intussuscepted ileum, 40 cm distant from the ileocoecal valve (fig. 1). Due to its severe ischaemic state and the impossibility of reducing the intussusception, the involved tract was resected laparoscopically. A polypoid hamartoma was found in the specimen. The postoperative course was normal and the patient was discharged on the 3rd postoperative day. As reported by the authors, the typical clinical presentation of adult intussusception is abdominal pain with tenderness and a palpable abdominal mass, while the pathognomonic “currant jelly stool” is more frequent in paediatric patients. In our case the diagnostic difficulty arose from the absence of a palpable abdominal mass and the limited utility of US and CT scan. However, the characteristic radiological findings of “target”, “pseudokidney” or “sausage” signs depend on factors such as the oedematous wall of the intussusception, the tract length, the cut axis, etc... [2]. We agree with the authors that recognition of the intussusception in an adult patient may often be difficult and may represent a major challenge for an inexperienced surgeon, due to the importance of prompt surgical treatment. What we consider essential is accurate clinical evaluation, which in some cases may be assisted by radiological investigations. We do however advocate the use of laparoscopy, especially when the diagnosis is unclear [3]. Emanuele Baldassarre, Ilaria Prosperi Porta, Giovanni Torino, Gabriele Valenti. Department of Surgery, San Pietro Hospital, Fatebenefratelli, Rome