American College of Radiology

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October 16, 2017

Don’t routinely recommend follow-up for nonobstructed, asymptomatic, isolated, short-segment jejunojejunal intussusception in adults.

Transient, idiopathic jejunojejunal intussusception in adult patients can be identified on MDCT in the absence of gastrointestinal pathology. In patients without an identifiable lead point mass lesion, imaging characteristics that favor the transient variety include short length (≤ 3.5 cm) and absence of bowel dilation. Self-limited jejunojejunal intussusception can occur in the absence of any bowel disease, or the finding may indicate an infectious or inflammatory process, such as enteritis or Celiac disease. If CT reveals an asymptomatic short-segment, isolated jejunojejunal intussusception (no bowel wall thickening or mesenteric inflammation, no bowel obstruction, no lead point) follow-up imaging should not be routinely recommended. Decisions regarding the need for additional work-up and follow up imaging should be made on clinical grounds.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

(1-5) The American College of Radiology (ACR) initially solicited expert opinion from physician leaders with its Board of Chancellors. A working group was then formed to further identify common clinical scenarios in which imaging may be misused and should be reconsidered. Members of the group included the physician chairs or vice chairs of seven ACR commissions such as Quality and Safety, Appropriateness Criteria and Metrics. An initial list of topics was narrowed down based on the highest potential for improvement, representing a broad range of tests and the availability of strong guidelines. Members then researched specific recommendations and evidentiary statements based on their expertise. Recommendations that were too general or were well covered by other existing measures and initiatives were eliminated to identify the final five things list.

(6-10) The Choosing Wisely initiative was presented to the organization’s physician leaders at a Board of Chancellors meeting and a working group selected five initial low-value imaging targets for reduced utilization. The second set of targets was created by the following working group, with the goals of minimizing unnecessary imaging and biopsy generated by discovery of incidental findings, improving patient safety through reduced radiation exposure, and reducing unnecessary consultations based on imaging findings.

  • Pamela T. Johnson, MD, Chair, Choosing Wisely Recommendations
  • Jacqueline A. Bello, MD, FACR, Chair of Commission on Quality and Safety
  • Mythreyi B. Chatfield, PhD, Executive Vice President for Quality and Safety
  • Jonathan Flug, MD, MBA, Quality Management Committee
  • Jenny K. Hoang, MBBS, lead author on ACR White Paper for Managing Incidental Thyroid Nodules
  • Alec J. Megibow, MD, MPH, FACR, Committee on Economics – Body Imaging Commission
  • Pari V. Pandharipande, MD, MPH, Chair of Committee on Incidental Findings
  • Saurabh Rohatgi, MD, Committee on Quality Experience – Commission on Patient and Family Centered Care

Research: For the topics related to incidental findings on imaging exams, the American College of Radiology has created evidence-based white papers to provide guidance to practicing radiologists on making management recommendations. The white paper publications and additional relevant literature serve as the evidence supporting those recommendations. For the remaining recommendations pertaining to body CT protocol design, published literature was reviewed to define acceptable indications for multiphase protocols.

ACR’s disclosure and conflict of interest policy can be found at www.acr.org.

Sources

Warshauer DM, Lee JK. Adult intussusception detected at CT or MR imaging: clinical-imaging correlation. Radiology. 1999 Sep;212(3):853-60. PubMed PMID: 10478257.

Rea JD, Lockhart ME, Yarbrough DE, Leeth RR, Bledsoe SE, Clements RH. Approach to management of intussusception in adults: a new paradigm in the computed tomography era. Am Surg. 2007 Nov;73(11):1098-105. PubMed PMID: 18092641.

Olasky J, Moazzez A, Barrera K, Clarke T, Shriki J, Sohn HJ, Katkhouda N, Mason RJ. In the era of routine use of CT scan for acute abdominal pain, should all adults with small bowel intussusception undergo surgery? Am Surg. 2009 Oct;75(10):958-61. PubMed PMID: 19886144.