Clinical History
A 55-year-old female was admitted to our emergency ward with cramping abdominal pain, emesis, emission of mucus and blood from the anal orifice. She reported intermittent diarrhoea and a significant
weight loss in the previous six months. A physical examination done revealed a mesogastric palpable mass without other pathological signs.
Imaging Findings
A 55-year-old female was admitted to our emergency ward with cramping abdominal pain, emesis, emission of mucus and blood from the anal orifice. She reported intermittent diarrhoea and a significant
weight loss in the previous six months. A physical examination done revealed a mesogastric palpable mass without other pathological signs. X-ray examination results of the abdomen were found to be
negative. The barium enema test results revealed the presence of a stenosis in the jejunum, associated with a typical “malabsorption pattern”. The patient underwent MRI after oral
administration of polyethylene glycol as contrast agent. MR examination confirmed the signs of a malabsorption syndrome and revealed a characteristic “target” image, suggestive of a
jejunum-jejunal invagination.. Specific serological tests evidenced the elevation of IgA and IgG antigliadin and was positive for IgA anti-endomysium and antireticulin. A bowel biopsy demonstrated
subtotal villous atrophy. So coeliac disease was identified as the cause of the intussusception.
Discussion
During the last two decades, the classic clinical presentation of coeliac disease has been modified, and oligo- to asymptomatic courses are increasingly being found; so this disorder is now
frequently diagnosed in adults. Sometimes the presence of a specific complication can reveal an underlying undetected coeliac disease. Small bowel invagination is not a widely recognized complication
of coeliac disease; it is problaby due to chronic hyperperistalsis, which characterizes this pathology. Intussusception associated with coeliac sprue often presents in an atypical way: elementary
forms, spontaneously resolvent and recidivious. These patients often suffer from a prolonged abdominal pain and extraintestinal symptoms of occult coeliac disease. In our case, the woman was
absolutely unaware of her enteropathy. CT or MRI can play a vital role in the diagnosis of bowel invagination; they also offer the necessary information about the exact location of the mass, its
shape and fat content, possible underlying pathology and dilatation of the bowel proximally. MRI represents an excellent diagnostic method for imaging of the small bowel because of its optimal
soft-tissue contrast and multiplanar imaging capabilities. Even if the final diagnosis of coeliac disease is based on biopsy, MRI can help to detect suspected signs of this malabsorption syndrome and
its complicating lesions. In cases of coeliac sprue, MRI findings include dilatation of small bowel loops, wall thickening, “ileal-jejunalization”, jejunoileal fold pattern reversal.
Invagination can be visualized as a typical pattern of the target sign. MRI also permits the correct differentiation from Chron’s disease: in this case, the typical signs are small bowel wall
thickening (>4 mm) in the terminal ileum, with lumen stenosis, abnormalities of perivisceral fat tissue, mesenteric lymphadenopathy and abdominal abscess.
Differential Diagnosis List
Jejunum-jejunal invagination in a patient with coeliac disease.
Final Diagnosis
Jejunum-jejunal invagination in a patient with coeliac disease.
