Adult intussusception: presentation, management, and outcomes of 148 patients.

BACKGROUND: Intussusception is a predominantly pediatric diagnosis that is not well characterized among adults. Undiagnosed cases can result in significant morbidity, making early recognition important for clinicians. STUDY OBJECTIVES: We describe the presentation, clinical management, disposition, and outcome of adult patients diagnosed with intussusception during a 13-year period. METHODS: A retrospective study of consecutive adult patients diagnosed with intussusception at a tertiary academic center was carried out from 1996 to 2008. Cases were identified using International Classification of Diseases, 9(th) Revision codes and a document search engine. Data were abstracted in duplicate by two independent authors. RESULTS: Among 148 patients included in the study, the most common symptoms at presentation were abdominal pain (72%), nausea (49%), and vomiting (36%). Twenty percent were asymptomatic. Sixty percent of cases had an identifiable lead point. Patients presenting to the emergency department (ED) (31%) had higher rates of abdominal pain (relative risk [RR] 5.7) and vomiting (RR 3.4), and were more likely to undergo surgical intervention (RR 1.8) than patients diagnosed elsewhere. There were 77 patients who underwent surgery within 1 month; patients presenting with abdominal pain (RR 2.2), nausea (RR 1.7), vomiting (RR 1.4), and bloody stool (RR 1.9) were more likely to undergo surgery. CONCLUSIONS: Adult intussusception commonly presents with abdominal pain, nausea, and vomiting; however, approximately 20% of cases are asymptomatic and seem to be diagnosed by incidental radiologic findings. Patients presenting to an ED with intussusception due to a mass as a lead point or in an ileocolonic location are likely to undergo surgical intervention.

CT of small-bowel ischemia associated with obstruction in emergency department patients: diagnostic performance evaluation.

PURPOSE: To retrospectively evaluate the diagnostic performance of computed tomography (CT) for detection of small-bowel ischemia in emergency department patients with abdominal pain and to compare the prospective interpretation with a retrospective interpretation by using surgical or pathologic findings as the reference standard. MATERIALS AND METHODS: The HIPAA-compliant study was approved by the institutional review board, and patients consented to research authorization. Sixty patients (61 examinations) (25 male, 35 female patients; median age, 67 years; range, 0.9-89.7 years) with acute abdominal pain underwent immediate abdominal and pelvic CT and subsequent surgery of the small bowel within 7 days of CT. Prospective radiologic reports were reviewed for diagnosis of small-bowel obstruction and ischemia. Two gastrointestinal radiologists performed blinded, independent, retrospective review of the CT studies with no clinical data other than presence of acute abdominal pain. The reviewers categorized CT signs of obstruction and ischemia and estimated diagnostic certainty. Discordant findings were resolved by consensus review by a third gastrointestinal radiologist. CT interpretations were compared with prospective interpretations and surgical or pathologic findings. Sensitivity and specificity estimates with confidence intervals were calculated. Fisher exact and chi2 tests were used to assess associations between CT signs and the diagnosis of ischemia; kappa statistics were used to estimate agreement between readers. RESULTS: In 27 (44%) of 61 CT studies, small-bowel ischemia was surgically or pathologically confirmed. Sensitivity and specificity for the diagnosis of ischemia were, respectively, 14.8% and 94.1% for prospective interpretations, 29.6% and 91.2% for reader 1, 40.7% and 85.3% for reader 2, and 51.9% and 88.2% for the consensus review. Decreased segmental enhancement was the most specific sign for small-bowel ischemia (P = .001), and its recognition would have improved the diagnostic performance of all readers. There was a significant association of the small-bowel feces sign with the presence of small-bowel ischemia (P = .046). CONCLUSION: Diagnostic performance assessment of CT for the diagnosis of small-bowel ischemia revealed poor prospective interpretation sensitivity.

Differentiation of nonperforated from perforated appendicitis: accuracy of CT diagnosis and relationship of CT findings to length of hospital stay.

PURPOSE: To determine retrospectively the sensitivity and specificity of computed tomographic (CT) signs in differentiating acute nonperforated appendicitis from perforated appendicitis and to compare CT findings with the length of hospital stay. MATERIALS AND METHODS: Institutional Review Board approval was obtained for this study, and patient informed consent was obtained for record review for research purposes. Two radiologists were blinded to patient identification but were informed that all patients presented to the emergency department with abdominal pain and underwent appendectomy. Radiologists independently reviewed CT images of 86 consecutive patients (45 males, 41 females; mean age, 33.7 years; age range, 8.2-87.1 years) who presented to the emergency department with acute abdominal pain, who underwent CT after initial emergency department assessment, and who underwent appendectomy within the subsequent 24 hours. Individual findings and confidence level for the diagnosis of perforated appendicitis were noted. Consensus interpretation was performed with a third radiologist. The consensus CT findings were correlated with the surgical and pathologic findings by using chi(2) or Fisher exact tests for univariate analysis and logistic regression for multiple variable analysis. Wilcoxon rank sum tests were used to assess the association between consensus CT findings and length of hospital stay. RESULTS: Twenty-one (24%) of the 86 patients had appendiceal perforation. Extraluminal air and either moderate or severe periappendiceal inflammatory stranding were statistically significant independent predictors for perforation (P < .001). A focal defect in enhancing appendiceal wall was significantly associated with perforation (P < .001) and had a sensitivity of 58.8% and specificity of 85.7% on consensus review, with eight false-positive results. There was a strong association between the degree of periappendiceal inflammatory stranding and the length of hospital stay (P < .001). CONCLUSION: Extraluminal air and moderate or severe periappendiceal inflammatory stranding are statistically significant independent predictors for appendiceal perforation and are associated with increased hospital stay.