Case Report Open Access
Copyright ©2010 Baishideng. All rights reserved.
World J Gastrointest Surg. Mar 27, 2010; 2(3): 85-88
Published online Mar 27, 2010. doi: 10.4240/wjgs.v2.i3.85
A case of postoperative recurrent intussusception associated with indwelling bowel tube
Yoshitaka Furuya, Takashi Wakahara, Harutoshi Akimoto, Chu Manh Long, Department of Surgery, Sodegaura Satsukidai Hospital, 5-21 Nagauraekimae, Sodegaura, Chiba 299-0246, Japan
Hironobu Yanagie, Cooperative Unit of Medicine and Engineering Research, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
Hiroshi Yasuhara, Surgical Center, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan
Author contributions: Furuya Y and Wakahara T wrote the paper; Akimoto H and Long CM collected and analyzed the data; Yanagie H and Yasuhara H critically revised the paper for important intellectual content.
Correspondence to: Yoshitaka Furuya, MD, PhD, Department of Surgery, Sodegaura Satsukidai Hospital, 5-21 Nagauraekimae, Sodegaura, Chiba 299-0246, Japan.
Telephone: +81-438-621113 Fax: +81-438-636213
Received: September 7, 2009
Revised: November 12, 2009
Accepted: November 19, 2009
Published online: March 27, 2010


Intussusception is quite uncommon in adults. We report a rare case of a 76-year-old man with small bowel intussusception induced by two indwelling bowel tubes, the first a jejunal feeding tube and the second an ileus tube. After complete reduction of the first intussusception caused by the jejunal feeding tube and adhesion, re-intussusception occurred due to the postoperative adhesion and ileus tube inserted into the bowel after the previous operation for intussusception. Finally, the part of the jejunum with re-intussusception and adhesion, including the place where the previous reduced intussusception had occurred, was resected. This case is a reminder that when there is no mucosal lesion other than an indwelling bowel tube or a hard adhesion/inflammation around intussusception, the patient should be operated on without delay for resection of the intussusception to prevent re-intussusception, even if the resected bowel is predicted to be long.

Key Words: Intussusception, Recurrence, Feeding tube, Ileus tube, Small intestine


Intussusception is a rare cause of postoperative intestinal obstruction in adults[1,2] and recurrent intussusception seldom occurs in patients who have undergone surgical reduction[3]. We present here the case of a patient with small bowel intussusception induced by jejunal feeding tube placement and with re-intussusception induced by an ileus tube inserted after operative reduction of intussusception. Finally, both the part of the jejunum with re-intussusception including adhesion and the place where the previous reduced intussusception had occurred was resected.


A 76-year-old man was transferred to our hospital with a chief complaint of dyspnea. He had a history of chronic obstructive pulmonary disease (COPD) combined with emphysema, bronchial asthma and distal gastrectomy for gastric ulcer. After being given artificial respiration for 1 mo because of deterioration in dyspnea, unexpected dysphagia appeared, the cause of which could not be detected by computed tomography and gastrointestinal fiberscope. A Witzel jejunostomy was carried out to allow feeding because of the impossibility of swallowing and his small residual stomach, and early enteral nutrition was begun on the 3rd postoperative day. About 3 wk after the initial feeding tube placement, the patient had occasional episodes of vomiting and abdominal pain without palpation of an abdominal mass. As an X-ray of the abdomen revealed distention of the proximal jejunum, a nasogastric tube was inserted into the stomach to decompress the jejunal gas. Because we assumed there was postoperative adhesion of the jejunum, we performed an X-ray examination using a water-soluble contrast medium from the nasogastric tube and jejunal feeding tube. This revealed the retention of contrast medium from the stomach to the proximal jejunum and normal caliber of the distal jejunum. Judging from the small bowel series results, we did not suspect intussusception associated with the feeding tube but rather postoperative adhesive bowel obstruction or torsion around the tube. We therefore performed exploratory laparotomy. A fleshy sausage-like tubular intestinal mass 10 cm in length was found at the proximal jejunum, about 15 cm distal to the entry of the tube. The intussusception, which showed edematous changes without necrosis, was antegrade in direction and jejunojejunal in nature (Figure 1A and B). The two sites of fixation on the jejunostomy were still in position without rotation, and were well attached to the peritoneum. Complete reduction of the intussusception, and appendectomy and adhesiotomy of the mesentery of the jejunum, 30 cm distal from the entry of the tube, was performed. After this procedure, an ileus tube without an inflating balloon (to avoid ileus relapses) was put into the distal jejunum far beyond the adhesiotomy of the adhesional point. On the 5th postoperative day, because an X-ray of the abdomen revealed dilated jejunal gas and a change in the position of the top of the ileus tube, we tried to examine the jejunum again, using contrast medium, to confirm whether the tube had moved and the ileus existed. However, the bowel passage was normal except that the tube had moved toward the proximal position. In addition, the patient had been experiencing intermittent abdominal pain since the abnormal gas had appeared. An abdominal computed tomography (CT), which was performed after decompressing the abnormal jejunal gas, demonstrated a target sign in the pelvis (Figure 2). Because we diagnosed the patient as having a ‘recurrent intussusception’ and the patient consented to an operation on the 18th postoperative day, exploratory laparotomy was performed again. A 15-cm long mass, as well as the jejunal intussusception that we had experienced at the last surgery, was found at the distal jejunum at a different point to the last intussusception (Figure 3A and B). The jejunal intussusception was found between the tip of the ileus tube, which had moved back to the proximal jejunum, and the adhesion of the stump of the resected appendix and mesentery of the small intestine. A 50-cm segment of the jejunum with ‘re-intussusception’ and adhesion, including the place of the previously reduced intussusception, was resected. Because of the difference in the size of the bowel between the proximal and distal sides, functional end-to-end anastomosis was performed without any change to the previous feeding tube. To prevent ileus or ‘re-recurrent intussusception’, the ileus tube was not inserted in the bowel. Enteral nutrition was started again on the 3rd postoperative day and the patient’s

Figure 1
Figure 1 First intussusception. A: The intussusception was 10 cm in length (arrowhead), showed slightly edematous changes without necrosis, and started at a site about 15 cm distal from the entry of the jejunal feeding tube; B: Schematic diagram of the intussusception.
Figure 2
Figure 2 Abdominal CT appearance of the intussusception with a target mass (arrowhead) in the pelvis.
Figure 3
Figure 3 Recurrent intussusception. A: A 15-cm long re-intussusception was found at the distal jejunum at a separate point of the last intussusception. Arrowhead shows the repair point of the adhesiotomy at the first intussusception; B: Schematic diagram of the recurrent intussusception.

postoperative course was uneventful. Examination of CT and contrast medium injection of the feeding tube revealed no problems 6 mo postoperatively.


It is generally believed that any lesion in the bowel wall or irritant within the bowel lumen that alters normal peristaltic activity is able to initiate an invagination[1,4]. On the other hand, uneven return of peristalsis after surgery, with possible local spasms or edema of the bowel, is a plausible explanation in cases without obvious lead points[5]. Ein et al[6] claimed that postoperative intussusceptions are likely to be caused by altered peristalsis following prolonged and excessive manipulation with drying and bruising of the bowel, extensive preperitoneal dissection, abdominal serum electrolyte levels, local hypoxia, anesthetic agents, postoperatively administered drugs, or neurogenic factors. In our case, the location of the ‘re-intussusception’ was different from that of the first intussusception that had been reduced. The main cause of the ‘re-intussusception’ may have been the ileus tube and adhesion, whilst the first intussusception was caused by the feeding tube and adhesion. In the present case, there were no pathological problems, such as a tumor, in our resected specimen. The probable causes of this intussusception are believed to be: (1) restriction of peristalsis due to adhesion of mesentery or bowel in front of or behind the tip of the tube; (2) excessive dilatation of the small intestine before decompression; (3) a decrease in the degree of freedom of the small intestine due to the presence of a tube in the bowel which acts as a stent[7]; (4) rise of abnormal abdominal pressure due to coughing; (5) abnormal and irregular peristalsis without cooperation; and (6) functional disorder of ganglion cells or neuron transmission after expanded bowel etc. However, the mechanism of intussusception that occurs following the placement of an ileus tube or jejunal feeding tube is still unknown.

All patients with enteric lesions who have not had a previous laparotomy should undergo resection without reduction because of the high incidence of associated malignancy[8]. Especially in cases of colonic intussusception, many researchers recommend resection without reduction[1,8-10]. On the other hand, the argument for initial resection in small bowel intussusception may not be as convincing as for large bowel intussusception, because the incidence of malignancy ranges from 1%-40% and the vast majority of these are metastasis[1,8-11]. Eisen et al[11] stated that small bowel intussusception should be reduced only in patients in whom a benign diagnosis has been made preoperatively or in patients in whom resection may result in short gut syndrome. If we consider our case only, resection, rather than reduction, was necessary for our intussusception to prevent ‘re-recurrent intussusception’ as the proximal jejunum had become dilated due to the restriction of bowel movement, and there was hard adhesion of the mesentery or the bowel around the place of the first intussusception. While recurrence rates of 3% (after surgical reduction) to 10% (after hydrostatic reduction) have been reported following treatment of primary intussusception[12], no recurrence has been recorded following surgical reduction of post operative intussusception after up to 20 years follow-up[13]. Yang et al[3] concluded that recurrent intussusception seldom occurred in patients who underwent surgical reduction. Three case reports[2,14,15] have reported ‘recurrent small bowel intussusception after operation of small bowel intussusception’ (Table 1). The recurrent rate of ‘small bowel intussusception’ is only about 0.2% in English publications, according to the results of our searches on PubMed.

Table 1 Summary of recurrent intussusception after operation of small bowel intussusception in adults.
Authors (year)AgePreoperative diagnosisDiagnosis methodSurgical TreatmentNature of Lesion
1Felix et al[2] (1976)34Acute abdomenExploratory laparotomyResectionLymphoma nodule (Burkitt’s lymphoma)
Mechanical obstructionBarium mealResectionNo tumor
2Dong et al[14] (2004)25IntussusceptionNot describedResectionHamartoma (Peutz-jeghers syndrome)
IntussusceptionNot describedResectionHamartoma
3Akimaru et al[15] (2006)41IntussusceptionCTReduction and resectionHamartoma (Peutz-jeghers syndrome)
4Our case76IleusExploratory laparotomyReductionNo tumor (Feeding tube and adhesion)
IntussusceptionCTResectionNo tumor (Ileus tube and adhesion)

The classic pediatric symptoms of intussusception such as abdominal pain, mass, and blood per rectum are rarely found in adults, in whom the predominant symptom is bowel obstruction. Consequently, intussusception is often initially misdiagnosed in the adult population[1,9-11,16]. As mentioned above, we first misdiagnosed the patient with postoperative adhesive bowel obstruction or torsion around the tube because there was no palpable abdominal mass and the only symptoms of intestinal obstruction that had appeared were abdominal pain and vomiting. Aware of the difficulty of diagnosing intussusception from symptoms and contrast medium studies, because we had experienced intussusception in this patient before and despite a negative study using contrast medium, ‘re-intussusception’ was later suspected when he reported intermittent abdominal pain. This diagnosis was confirmed by using CT. Our experience in this case confirms earlier reports that the diagnosis of intussusception is difficult to make before surgery. Some researchers have claimed that a diagnosis of intussusception was suspected preoperatively in 14%-75% of patients[8,11,16,17]. Abdominal CT is the most sensitive radiologic method for confirming a diagnosis of intussusception, with a reported diagnostic sensitivity of 71.4%-87.5%[8,11,16-21]. Even though high resolution CT is now widely used in many institutions, misdiagnoses may occur due to human error when clinicians do not have experience of ‘intussusception’, limiting how many correct preoperative diagnoses can be made. Abdominal ultrasonography (US) is also a very useful and appropriate technique in the diagnosis of intussusception in adults[22], while contrast medium studies of the small intestine were able to confirm the diagnosis of intussusception preoperatively in only 17% of patients[16]. In obese cases or those with full bowel gas, it is difficult to accurately detect intussusception using US. Given these facts, a plural examination including CT, US, contrast studies, and Magnetic Resonance Imaging (MRI) is necessary to improve the diagnosis of intussusception.

In conclusion, the mechanism of the relationship between intussusception and a feeding or ileus tube has not been well understood. There may be complicating factors, such as adhesion, abnormal peristalsis, and the tube itself. When encountering a hard adhesion, inflammation on the bowel surface or a mesenteric obstruction in a patient who has had an intussusception, it is necessary to operate on the patient to resect the intussusception, including the adhesion, in order to prevent ‘re-intussusception’, even if it is predicted that the resected bowel will be long.


Peer reviewers: Tsukasa Hotta, MD, PhD, Second Department of Surgery, Wakayama Medical University, School of Medicine, 811-1, Kimiidera, Wakayama 641-8510, Japan; Vijay P Khatri, MB, ChB, FACS, Professor of Surgery, Department of Surgery, Division of Surgical Oncology, University of California, Davis Cancer Center, 4501 X Street, Suite 3010, Sacramento, CA 95817, United States

S- Editor Li LF L- Editor Hughes D E- Editor Yang C

1.  Begos DG, Sandor A, Modlin IM. The diagnosis and management of adult intussusception. Am J Surg. 1997;173:88-94.  [PubMed]  [DOI]  [Cited in This Article: ]
2.  Felix EL, Cohen MH, Bernstein AD, Schwartz JH. Adult intussusception; case report of recurrent intussusception and review of the literature. Am J Surg. 1976;131:758-761.  [PubMed]  [DOI]  [Cited in This Article: ]
3.  Yang CM, Hsu HY, Tsao PN, Chang MH, Lin FY. Recurrence of intussusception in childhood. Acta Paediatr Taiwan. 2001;42:158-161.  [PubMed]  [DOI]  [Cited in This Article: ]
4.  Takeuchi K, Tsuzuki Y, Ando T, Sekihara M, Hara T, Kori T, Kuwano H. The diagnosis and treatment of adult intussusception. J Clin Gastroenterol. 2003;36:18-21.  [PubMed]  [DOI]  [Cited in This Article: ]
5.  Holcomb GW 3rd, Ross AJ 3rd, O'Neill JA Jr. Postoperative intussusception: increasing frequency or increasing awareness? South Med J. 1991;84:1334-1339.  [PubMed]  [DOI]  [Cited in This Article: ]
6.  Ein SH, Ferguson JM. Intussusception--the forgotten postoperative obstruction. Arch Dis Child. 1982;57:788-790.  [PubMed]  [DOI]  [Cited in This Article: ]
7.  Wu TH, Lin CW, Yin WY. Jejunojejunal intussusception follo­wing jejunostomy. J Formos Med Assoc. 2006;105:355-358.  [PubMed]  [DOI]  [Cited in This Article: ]
8.  Azar T, Berger DL. Adult intussusception. Ann Surg. 1997;226:134-138.  [PubMed]  [DOI]  [Cited in This Article: ]
9.  Nagorney DM, Sarr MG, McIlrath DC. Surgical management of intussusception in the adult. Ann Surg. 1981;193:230-236.  [PubMed]  [DOI]  [Cited in This Article: ]
10.  Weilbaecher D, Bolin JA, Hearn D, Ogden W 2nd. Intussusception in adults. Review of 160 cases. Am J Surg. 1971;121:531-535.  [PubMed]  [DOI]  [Cited in This Article: ]
11.  Eisen LK, Cunningham JD, Aufses AH Jr. Intussusception in adults: institutional review. J Am Coll Surg. 1999;188:390-395.  [PubMed]  [DOI]  [Cited in This Article: ]
12.  Eke N, Adotey JM. Postoperative intussusception, causal or casual relationships? Int Surg. 2000;85:303-308.  [PubMed]  [DOI]  [Cited in This Article: ]
13.  Soper RT, Brown MJ. Recurrent acute intussusception in children. Arch Surg. 1964;89:188-198.  [PubMed]  [DOI]  [Cited in This Article: ]
14.  Dong K, Li B. Peutz-Jeghers syndrome: case reports and update on diagnosis and treatment. Chin J Dig Dis. 2004;5:160-164.  [PubMed]  [DOI]  [Cited in This Article: ]
15.  Akimaru K, Katoh S, Ishiguro S, Miyake K, Shimanuki K, Tajiri T. Resection of over 290 polyps during emergency surgery for four intussusceptions with Peutz-Jeghers syndrome: Report of a case. Surg Today. 2006;36:997-1002.  [PubMed]  [DOI]  [Cited in This Article: ]
16.  Zubaidi A, Al-Saif F, Silverman R. Adult intussusception: a retrospective review. Dis Colon Rectum. 2006;49:1546-1551.  [PubMed]  [DOI]  [Cited in This Article: ]
17.  Wang LT, Wu CC, Yu JC, Hsiao CW, Hsu CC, Jao SW. Clinical entity and treatment strategies for adult intussusceptions: 20 years' experience. Dis Colon Rectum. 2007;50:1941-1949.  [PubMed]  [DOI]  [Cited in This Article: ]
18.  Gayer G, Apter S, Hofmann C, Nass S, Amitai M, Zissin R, Hertz M. Intussusception in adults: CT diagnosis. Clin Radiol. 1998;53:53-57.  [PubMed]  [DOI]  [Cited in This Article: ]
19.  Erkan N, Haciyanli M, Yildirim M, Sayhan H, Vardar E, Polat AF. Intussusception in adults: an unusual and challenging condition for surgeons. Int J Colorectal Dis. 2005;20:452-456.  [PubMed]  [DOI]  [Cited in This Article: ]
20.  Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, Theodosopoulos T. Intussusception of the bowel in adults: a review. World J Gastroenterol. 2009;15:407-411.  [PubMed]  [DOI]  [Cited in This Article: ]
21.  Yakan S, Caliskan C, Makay O, Denecli AG, Korkut MA. Intussusception in adults: clinical characteristics, diagnosis and operative strategies. World J Gastroenterol. 2009;15:1985-1989.  [PubMed]  [DOI]  [Cited in This Article: ]
22.  Boyle MJ, Arkell LJ, Williams JT. Ultrasonic diagnosis of adult intussusception. Am J Gastroenterol. 1993;88:617-618.  [PubMed]  [DOI]  [Cited in This Article: ]