Successful endoscopic reduction of rare post-ESD colonic intussusception: A case report

Abstract

Colonic intussusception after endoscopic submucosal dissection (ESD) is an uncommon, yet clinically significant complication. Therapeutic approaches for postoperative intussusception encompass conservative management, endoscopic reduction, and surgical intervention. We present a case involving a woman in her early 40s who experienced acute abdominal pain and fever shortly after ESD for a large ascending colonic adenoma. Contrast-enhanced computed tomography (CECT) of the abdomen confirmed intussusception without bowel ischemia. Immediate colonoscopic reduction was successfully performed, followed by conservative management. The patient achieved complete recovery with no recurrence at 3-month follow up. This case suggests that in patients developing post-ESD intussusception with no evidence of bowel necrosis or perforation, primary endoscopic intervention may be attempted and can be associated with favorable outcomes, potentially reducing the need for surgical management.

Introduction

Intussusception is characterized by the invagination of a segment of the intestine into an adjacent segment, termed the intussusceptum and intussuscipiens, respectively. While common in pediatric populations, adult intussusception is uncommon, accounting for approximately 5% of all cases. ¹ Typically, adult intussusceptions have identifiable lead points, often tumors or polyps. ² Postcolonoscopy intussusception, especially after therapeutic procedures like polypectomy or endoscopic submucosal dissection (ESD), is exceedingly rare, with limited reports in the literature.^3,4 Proposed pathophysiological mechanisms include localized mucosal edema at the resection site acting as a transient lead point, hyperperistalsis induced by insufflation and suction, and vacuum forces generated during scope withdrawal. Traditional management of adult intussusception has emphasized surgical resection to relieve obstruction and address underlying pathology. Recent evidence, however, indicates that endoscopic reduction followed by conservative care can successfully resolve select cases of postendoscopic intussusception. Here, we present a case of colonic intussusception following ESD, which was managed successfully with endoscopic reduction and conservative treatment.

Patient information

In April 2025, a woman in her early 40s without surgical history was admitted for ESD of a 40mm ascending colonic adenoma at Affiliated Jinhua Hospital, Zhejiang University School of Medicine. Following comprehensive preoperative evaluation during hospitalization to exclude contraindications, the patient underwent ESD. The submucosal injection solution consisted of 25 mg sodium hyaluronate dissolved in 20 mL normal saline with 0.004% methylene blue. All ESD procedures utilized an ERBE VIO 200S electrosurgical generator (Endo-cut Q mode, effect 3, duration 2, interval 4; ERBE Elektromedizin, Tübingen, Germany) coupled with a VedKnife (VDK-KM-15-200-D; Jiangsu Vedkang Medical Science and Technology Co., Jiangsu, China). At the lesion's epicenter, a feeding vessel (diameter ≈2 mm) was visualized and prophylactically ablated using soft-coagulation mode (80 W) via hot hemostatic forceps (HBF-16/1800; Micro-Tech Endoscopy, Nanjing, China).

The procedure was completed without immediate complications in 39 minutes (cecal intubation: 3 minutes). All endoscopic procedures were performed under CO₂ insufflation. The mucosal defect was secured with clips (Figure 1), and residual gas was aspirated during colonoscope withdrawal. Postoperative management included oxygen therapy, continuous electrocardiogram monitoring, Nil Per Os status, and intravenous fluid replacement.

Figure 1.

(a) A 40mm adenoma was found in the ascending colon during withdrawal. (b) At the lesion's epicenter, a feeding vessel (diameter ≈2 mm) was visualized. (c) The procedure was completed without immediate complications. (d) The mucosal defect was closed with clips.

Clinical findings

Approximately 8 hours postprocedure, she reported sudden onset of abdominal pain accompanied by low-grade fever. On examination, vital signs revealed mild tachycardia but otherwise stable parameters. Abdominal palpation disclosed tenderness localized to the right abdomen without signs of peritoneal irritation.

Diagnostic assessment

Laboratory findings showed elevated leukocytes (13,100/µL) and elevated C-reactive protein (CRP, 2.4 mg/dL). Contrast-enhanced computed tomography (CECT) of the abdomen demonstrated the characteristic target sign indicative of ascending colonic intussusception at the ESD site (Figure 2). There was no radiological evidence of bowel ischemia or perforation.

Figure 2.

CECT of the abdomen demonstrated the characteristic target sign indicative of ascending colonic intussusception at the ESD site (white arrows). CECT: Contrast-enhanced computed tomography; ESD: endoscopic submucosal dissection.

Therapeutic intervention

An emergency colonoscopy was performed, revealing marked mucosal edema and a ball-like protrusion at the site of previous ESD clips (Figure 3). Gentle air insufflation and careful manipulation of the colonoscope successfully reduced the intussusception. Moreover, the clips were subsequently removed to avoid further impaction. Subsequent conservative management included bowel rest, intravenous hydration, and antibiotic coverage with meropenem (1 g intravenously every 8 hours for 3 days).

Figure 3.

(a) The post-ESD site demonstrated edematous mucosa with a violaceous-erythematous appearance. (b) A ball-like protrusion at the site of previous ESD clips. ESD: endoscopic submucosal dissection.

Follow up and outcomes

Symptoms resolved progressively over the next 48 hours, accompanied by normalization of hematologic parameters and inflammatory markers (CRP). Thus, the diet was advanced to liquids on postoperative day 3 and meropenem was discontinued on day 4. The patient was discharged without further complications. She has been followed up in the outpatient clinic 3 months after the procedure, and no recurrence of abdominal pain or other gastrointestinal symptoms was reported. Repeat colonoscopy revealed a scar in the ascending colon (Figure 4).

Figure 4.

Repeat colonoscopy revealed a scar in the ascending colon.

Discussion

Adult colonic intussusception is an exceedingly rare diagnosis, accounting for only approximately 5 % of intussusception cases and about 1 % of bowel obstructions in adults. ⁵ Postcolonoscopy intussusception is even more uncommon within this group. The first reported case following colonoscopy was described by Yamazaki et al. in 2000. ⁶ According to recent case series, only 20 cases of postcolonoscopy or postendoscopic intussusception in adults have been reported worldwide as of 2025, including cases following polypectomy, endoscopic mucosal resection (EMR), or ESD (Table 1).^1–4,6–19 In most reports, symptoms developed within 24 hours after the procedure, with patients presenting with acute abdominal pain and imaging typically revealing intussusception. The majority of reported cases (16/20, 80%) were classified as colo-colic intussusceptions, while the remaining four (20%) were ileocolic. Almost all cases were localized to the right colon, except for a single case at the splenic flexure. ¹⁷ Regarding management, four patients were successfully treated conservatively, four underwent laparoscopic reduction, and three achieved reductions via endoscopic intervention. Surgical resection, a more invasive approach, was necessary in nine cases (six laparoscopic and three open segmental resections).

Table 1.

Clinical characteristics of reported adult cases of postcolonoscopy or postendoscopic intussusception.

Author/year	Age/sex	Intervention	Pain onset	Site/type	Treatment
Yamazaki et al. (2000) 6	48/M	Biopsy	Within hours	Cecal colo-colonic	Open ileocolic resection
Theodoropoulou et al. (2009) 7	19/M	None	7 hours	Ileocecal	Open right hemicolectomy
Ho et al. (2010) 8	32/M	EMR	Within hours	Cecal colo-colonic	Lap. reduction
Nachanani et al. (2012) 9	73/F	Biopsy	Within hours	Ascending colo-colonic	Lap. reduction
Lasithiosakis et al. (2012) 10	58/M	None	8 hours	Ileocecal	Open right hemicolectomy
Lee et al. (2013) 11	47/M	EMR	12 hours	Cecal colo-colonic	Lap. right hemicolectomy
Min et al. (2017) 12	31/M	Biopsy	Within hours	Cecal colo-colonic	Lap. ileocolic resection
Araki et al. (2018) 13	28/M	Biopsy	1 day	Cecal colo-colonic	Colonoscopic reduction
Hassan et al. (2018) 14	43/F	ESD	Within hours	Ascending colo-colonic	Conservative management
He et al. (2020) 1	54/F	EMR	4–5 hours	Transverse colo-colonic	Conservative management
Ahmed et al. (2020) 4	42/F	CSP	Within hours	Transverse colo-colonic	Conservative management
Moon et a1. (2022) 15	58/F	EMR	Within hours	Hepatic flexure colo-colonic	Conservative management
Lee et al. (2022) 16	69/M	EMR	12 hours	Ileocecal	Lap. ileocecectomy
Vadakkenchery et al (2022) 17	36/F	None	1 day	Splenic flexure colo-colonic	Lap. reduction
Jastaniah et al. (2023) 18	51/F	EMR	Within hours	Ileocecal	Lap. right hemicolectomy
Hashiguchi et al. (2023) 3	78/M	EMR	16 hours	Hepatic flexure colo-colonic	Colonoscopic reduction
Xiang et al. (2024) 19	61/M	CSP	11 hours	Ascending colo-colonic	Lap. right hemicolectomy
Xiang et al. (2024) 19	59/F	EMR	9 hours	Transverse colo-colonic	Lap. reduction
Mehmood et al. (2025) 2	71/M	CSP	Within hours	Ascending colo-colonic	Lap. right hemicolectomy
Our case	40 s/F	ESD	8 hours	Ascending colo-colonic	Colonoscopic reduction

CSP: cold snare polypectomy; EMR: endoscopic mucosal resection; ESD: endoscopic submucosal dissection; F: female; Lap.: laparoscopic; M: male.

Most adult intussusceptions arise around a fixed “lead point,” such as a neoplasm or polyp, whereas pediatric cases are often idiopathic. ⁵ In the postendoscopic setting, several mechanistic theories have been advanced. Localized hematoma or mucosal and submucosal edema at the resection site may create a transient lead point that precipitates invagination. ³ Luminal distension from insufflation followed by abrupt suction can generate negative pressure, drawing one bowel segment into the next. ¹⁴ Hyperperistalsis provoked by mechanical irritation or residual gas may further facilitate telescoping, especially in the mobile right colon.^11,14 Historically, adult intussusception has been managed with surgical resection to relieve obstruction and to exclude malignancy. In reported postcolonoscopy cases, the majority of patients underwent laparoscopy or laparotomy, and most required segmental colectomy. ² A small minority achieved reduction via colonoscopy alone or with adjunctive conservative measures; these patients uniformly lacked radiological or clinical signs of ischemia or perforation. ²

We hypothesized that the intussusception was likely triggered by a combination of postoperative mucosal edema and the space-occupying effect of the clips placed during ESD. Accordingly, suction during endoscope withdrawal or hypermotility induced by residual gas may serve as triggering factors. Given the suspected role of clips in triggering the intussusception, we elected to perform endoscopic clip retrieval as our primary therapeutic intervention. The patient tolerated the procedure well, with successful reduction of the intussusception and avoidance of surgical intervention. Our case introduces a novel treatment paradigm. After confirming colonic intussusception by CECT and excluding ischemia, we performed therapeutic colonoscopy, successfully reducing the invaginated segment. The patient then received close clinical monitoring, bowel rest, and intravenous antibiotics, with rapid symptomatic resolution and no surgical intervention. This successful organ-preserving strategy echoes the favorable outcomes seen in isolated reports of endoscopic reduction after EMR ³ or ESD for cecal adenoma. ¹³ However, our case represents the first documented successful endoscopic management of immediate post-ESD intussusception, potentially establishing endoscopic reduction as a viable first-line therapeutic option for this rare complication.

Conclusion

This case carries three important implications. First, endoscopists must maintain vigilance for intussusception in any patient presenting with acute pain following therapeutic colonoscopy, including ESD. Second, when imaging and clinical findings do not suggest compromised bowel viability, endoscopic reduction may be a viable, minimally invasive alternative to surgery. Third, further accumulation of similar cases will be essential to establish evidence-based selection criteria including integrating patient stability, imaging features, and endoscopic findings for nonoperative management of this rare complication.