Figure 1
Microscopic photo of the proces.
Histopathology showed a submucosal process containing fibrosis, small vessels and calcifications.
Invagination detected with Contrast Enhanced UltraSound
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsNorling R, Bergenfeldt M, Janjua HGR, Thorelius L.
Connected authors
47 years, female
Clinical History
A 47 year old female presented with a sudden onset of upper abdominal pain, nausea and emesis. Contrast-enhanced US indicated torsion of the small intestine or of a cyst.
Imaging Findings
A 47 year old female presented with a history of 5 hours of constant abdominal pain with periodical worsening. The pain had begun suddenly and was located in the epigastrium radiating to the right side of her back. The patient had nausea and alimentary vomiting. Stools were normal. Routine biochemistry was normal except for leukocytosis.
Plain films of the abdomen were normal.
As the pain persisted after admission to the hospital and biliary colic was suspected, an ultrasound was indicated. The bile ducts were normal, and without gallstones. A distended bowel loop with two wall layers was seen. (Figure 1) The patient was given a contrast medium (Sonovue, Bracco, Milan, Italy) intravenously. Contrast Enhanced US (CEUS) revealed a lack of contrast enhancement of the inner layer of this configuration, which implies lacking blood flow (Fig 2,3). Torsion of the intestine or a cyst was suggested.
Exploratory laparotomy revealed a small bowel (enteroenteric) intussusception with necrosis and ischemia. Resection of 30 cm of ischemic intestine and reconstruction with an end-to-end anastomosis was done.
Pathologic examination showed a 2 cm large process to be the leading point of the intussusception (Fig 4).
Histopathology showed a submucosal process containing fibrosis, small vessels and calcifications. The findings were compatible with a reactive process, and a diagnosis of healed schistosomiasis was considered (Fig 5). The patient had a history of travelling to parts of Africa and South-East Asia, where schistosomiasis is endemic.
Plain films of the abdomen were normal.
As the pain persisted after admission to the hospital and biliary colic was suspected, an ultrasound was indicated. The bile ducts were normal, and without gallstones. A distended bowel loop with two wall layers was seen. (Figure 1) The patient was given a contrast medium (Sonovue, Bracco, Milan, Italy) intravenously. Contrast Enhanced US (CEUS) revealed a lack of contrast enhancement of the inner layer of this configuration, which implies lacking blood flow (Fig 2,3). Torsion of the intestine or a cyst was suggested.
Exploratory laparotomy revealed a small bowel (enteroenteric) intussusception with necrosis and ischemia. Resection of 30 cm of ischemic intestine and reconstruction with an end-to-end anastomosis was done.
Pathologic examination showed a 2 cm large process to be the leading point of the intussusception (Fig 4).
Histopathology showed a submucosal process containing fibrosis, small vessels and calcifications. The findings were compatible with a reactive process, and a diagnosis of healed schistosomiasis was considered (Fig 5). The patient had a history of travelling to parts of Africa and South-East Asia, where schistosomiasis is endemic.
Discussion
Intussusception of the small intestine is uncommon in adults. The patient will present with symptoms of non-specific intestinal obstruction, and the exact diagnosis is usually not made before laparotomy. The condition may be either transient or persistent. The former variant is most common in infants, but may also be an incidental finding on CT-scanning in adults [1]. Persistent intussusceptions tend to have a lead-point, such as a Meckels diverticulum, an inflammatory fibroid polyp, a lymphoma or an adenoma [2].
A preoperative radiological diagnosis of intussusceptions may be obtained by means of CT or US. On both scannings, intussusception appears with a characteristic “cocarde structure” or “target sign”. In the longitudinal plane, the intussusception may appear as a ‘sausage-like structure’ or a pseudo-kidney configuration.
Besides giving the correct diagnosis, the radiological studies are of greatest value if they can predict the need for intervention. Presences of a lead-point, necrosis or perforation all indicate emergency surgery. CT has a high sensitivity in the detection of intussusceptions. Studies of the power to discriminate between the transient and persistent varieties show, that the diameter of the intussusception, presence of a lead point or bowel obstruction on CT-scanning are predictive for persistent intussusception [1,3].
US using Colour-Doppler (CD) is also widely used for discriminating between transient and persistent intussusception [4,5]. In one study, however, there was a discrepancy between the blood flow in the intussusceptions and the presence of necrosis and perforation as evaluated with CD and Power Doppler (PD) [6]. PD is more sensitive than CD in determining blood flow in the intestine [7], but the two methods have not been compared with regard to intussusception.
CEUS is a contrast specific technique with very high sensitivity also to minute amounts of contrast enhancement. Some ultrasound machines will colour-code the contrast signal superimposed on the grayscale image, which gives a morphological image of the state of blood flow in the tissues. In our experience, CEUS with this equipment is more accurate than CT or MRI to show a lack of blood circulation in necrosis and severe ischemiausing state of the art ultrasound machines.
CONCLUSION: In the current patient, CEUS successfully indicated a lack of blood flow in a segment of small intestine, which was later confirmed as ischemic and necrotic small bowel in the laparotomy. In fact, CEUS showed a complete lack of tissue perfusion, which lead to immediate surgery without further examinations. In conclusion, with proper training CEUS may have an important role in diagnosing intestinal ischemia due to intussusceptions or other forms of bowel strangulation, and may also be useful in predicting a need for immediate surgery.
A preoperative radiological diagnosis of intussusceptions may be obtained by means of CT or US. On both scannings, intussusception appears with a characteristic “cocarde structure” or “target sign”. In the longitudinal plane, the intussusception may appear as a ‘sausage-like structure’ or a pseudo-kidney configuration.
Besides giving the correct diagnosis, the radiological studies are of greatest value if they can predict the need for intervention. Presences of a lead-point, necrosis or perforation all indicate emergency surgery. CT has a high sensitivity in the detection of intussusceptions. Studies of the power to discriminate between the transient and persistent varieties show, that the diameter of the intussusception, presence of a lead point or bowel obstruction on CT-scanning are predictive for persistent intussusception [1,3].
US using Colour-Doppler (CD) is also widely used for discriminating between transient and persistent intussusception [4,5]. In one study, however, there was a discrepancy between the blood flow in the intussusceptions and the presence of necrosis and perforation as evaluated with CD and Power Doppler (PD) [6]. PD is more sensitive than CD in determining blood flow in the intestine [7], but the two methods have not been compared with regard to intussusception.
CEUS is a contrast specific technique with very high sensitivity also to minute amounts of contrast enhancement. Some ultrasound machines will colour-code the contrast signal superimposed on the grayscale image, which gives a morphological image of the state of blood flow in the tissues. In our experience, CEUS with this equipment is more accurate than CT or MRI to show a lack of blood circulation in necrosis and severe ischemiausing state of the art ultrasound machines.
CONCLUSION: In the current patient, CEUS successfully indicated a lack of blood flow in a segment of small intestine, which was later confirmed as ischemic and necrotic small bowel in the laparotomy. In fact, CEUS showed a complete lack of tissue perfusion, which lead to immediate surgery without further examinations. In conclusion, with proper training CEUS may have an important role in diagnosing intestinal ischemia due to intussusceptions or other forms of bowel strangulation, and may also be useful in predicting a need for immediate surgery.
Differential Diagnosis List
Intussusception of the small intestine
Final Diagnosis
Intussusception of the small intestine
References
[1] Rea JD, Lockhart ME, Yarbrough DE, Leeth RR, Bledsoe SE, Clements RH (2007) Approach to management of intussusception in adults: a new paradigm in the computed tomography era. Am Surg 73(11):1098-105. (PMID: 18092641)
[2] Kim YH, Blake MA, Harisinghani MG (2006) Adult intestinal intussusception: CT appearances and identification of a causative lead point. RadioGraphics 26:733-744. (PMID: 16702451)
[3] Lvoff N, Breiman RS, Coakley FV, Lu Y, Warren RS (2003) Distinguishing features of self-limiting adult small-bowel intussusception identified at CT. Radiology 227(1):68-72. (PMID: 12668740)
[4] Kong MS, Wong HF, Lin SL, Chung JL, Lin JN (1997) Factors related to detection of blood flow by color Doppler ultrasonography in intussusception. J Ultrasound Med 16(2):141-4. (PMID: 9166807)
[5] Lam AH, Firman K (1992) Value of ultrasonography including color Doppler in the diagnosis and management of long standing intussusception. Pediatr Radiol 22:112-114. (PMID: 1501937)
[6] Hanquinet S, Anooshiravani M, Vunda A, Le Coultre C, Bugmann P (1998) Reliability of color Doppler and power Doppler sonography in the evaluation of intussuscepted bowel viability. Pediatr Surg Int 13(5-6):360-2. (PMID: 9639617)
[7] Martinoli C, Pretolesi F, Crespi G, Bianchi S, Gandolfo N, Valle M, Derchi LE (1998) Power Doppler sonography: clinical applications. Eur J Radiol 27 Suppl 2:S133-40. (PMID: 9652513)
Case information
| URL: | https://www.eurorad.org/case/7225 |
| DOI: | 10.1594/EURORAD/CASE.7225 |
| ISSN: | 1563-4086 |
Figure 2
Ultrasound showed a distended bowel loop with two wall layers.
Green arrows shows the outer layer with contrast enhancement.
Red arrows shows the inner layer with lack of enhancement, which implies ischemic bowel-wall.
Figure 3
CEUS video
Play Video
CEUS revealed a lack of contrast enhancement in the inner layer, implying lack of blood flow. The outher layer with enhancment.
Figure 4
UltraSound video
Play Video
Ultrasound showed a distended bowel loop with two wall layers.
Figure 5
Macroscopic photo of the proces
Pathologic examination showed a 2 cm large process to be the leading point of the intussusception. Measure-line in cencimeters.
Microscopic photo of the proces.
Histopathology showed a submucosal process containing fibrosis, small vessels and calcifications.
Ultrasound showed a distended bowel loop with two wall layers.
Green arrows shows the outer layer with contrast enhancement.
Red arrows shows the inner layer with lack of enhancement, which implies ischemic bowel-wall.
Macroscopic photo of the proces
Pathologic examination showed a 2 cm large process to be the leading point of the intussusception. Measure-line in cencimeters.