Figure 1
Intestinal transit
Intestinal transit showing a filling defect in the cecum suggesting the existence of a mass (blue arrow).
An uncommon cause of intussusception
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsR. Sigüenza González, I. Jiménez Cuenca, T. Álvarez de Eulate García, M. Pina Pallín, B. De Andrés Asenjo, E. González Obeso
Connected authors
64 years, female
Clinical History
A 64 year-old-woman presented to the emergency department with intermittent abdominal pain and diarrhoea during the previous 48 hours. She had a history of similar episodes over the previous 5 months. On physical examination she experienced abdominal pain upon palpation of the right lower quadrant and epigastrium.
Imaging Findings
An acute abdominal series proved negative for bowel obstruction.
An intestinal transit demonstrated a filling defect situated in the cecum suggestive of the existence of a mass at that location (Fig.1).
CT of the abdomen and pelvis was performed and showed a large mass localized in the middle third of the transverse colon with interposition of the proximal ileum into the ascending-transverse colon suggestive of intussusception (Fig.2-4). The mass had a "target" appearance (Fig. 5).
The patient underwent an exploratory laparotomy with a right hemicolectomy. Histopathological examination of the specimen revealed a large cecal mass consistent with poorly differentiated adenocarcinoma (Fig.6).
An intestinal transit demonstrated a filling defect situated in the cecum suggestive of the existence of a mass at that location (Fig.1).
CT of the abdomen and pelvis was performed and showed a large mass localized in the middle third of the transverse colon with interposition of the proximal ileum into the ascending-transverse colon suggestive of intussusception (Fig.2-4). The mass had a "target" appearance (Fig. 5).
The patient underwent an exploratory laparotomy with a right hemicolectomy. Histopathological examination of the specimen revealed a large cecal mass consistent with poorly differentiated adenocarcinoma (Fig.6).
Discussion
In intussusception, a proximal bowel segment (intussusceptum) invaginates into the lumen of a distal bowel segment (intussuscipiens). Although intussusception is a common cause of obstruction in children, it is relatively rare in adults [1].
Adult intussusception occurs most often in the small bowel and is classified on the basis of location (ileocolic, enterocolic, colocolic) [2]. In contrast to intussusceptions in children, adult intussusceptions are often caused by a structural lesion like malignant neoplasms. Adenocarcinoma is the most common cause in the colon [3].
Usually the diagnosis is delayed because of the nonspecific nature of the symptoms. The classic paediatric presentation based on abdominal pain, currant-jelly stools and a palpable abdominal mass is rare in adults. Adult intussusceptions often present as chronic intermittent abdominal pain associated with nonspecific signs of bowel obstruction [4]. The diagnosis can be made in emergency situations with the aid of CT which may demonstrate the "target" lesion. Mesenteric fat and vessels are often visible within the bowel lumen, and varying degrees of proximal bowel dilatation may be present [5, 6]. Other imaging modalities like ultrasound and barium enema are more useful in children.
Management of symptomatic adult intussusception traditionally involves surgical resection as definitive treatment of the invaginating tumour [7]. Pneumatic reduction must be avoided in adults because of the risk of malignant neoplasm. In these cases hydrostatic reduction can cause bowel perforation and tumour cell disemination [8].
Adult intussusception occurs most often in the small bowel and is classified on the basis of location (ileocolic, enterocolic, colocolic) [2]. In contrast to intussusceptions in children, adult intussusceptions are often caused by a structural lesion like malignant neoplasms. Adenocarcinoma is the most common cause in the colon [3].
Usually the diagnosis is delayed because of the nonspecific nature of the symptoms. The classic paediatric presentation based on abdominal pain, currant-jelly stools and a palpable abdominal mass is rare in adults. Adult intussusceptions often present as chronic intermittent abdominal pain associated with nonspecific signs of bowel obstruction [4]. The diagnosis can be made in emergency situations with the aid of CT which may demonstrate the "target" lesion. Mesenteric fat and vessels are often visible within the bowel lumen, and varying degrees of proximal bowel dilatation may be present [5, 6]. Other imaging modalities like ultrasound and barium enema are more useful in children.
Management of symptomatic adult intussusception traditionally involves surgical resection as definitive treatment of the invaginating tumour [7]. Pneumatic reduction must be avoided in adults because of the risk of malignant neoplasm. In these cases hydrostatic reduction can cause bowel perforation and tumour cell disemination [8].
Differential Diagnosis List
Adult intussusception secondary to poorly differentiated adenocarcinoma.
Benign tumours
Adhesions
Lymphoid hyperplasia
Cystic fibrosis
Scleroderma
Inflammatory bowel disease
Appendicitis
Pancreatitis
Rectal foreign bodies
Final Diagnosis
Adult intussusception secondary to poorly differentiated adenocarcinoma.
References
[1] Kim Y, Blake M, Harisinghani M, Archer-Arroyo K, Hahn P, Pitman, Mueller P. (2006) Adult Intestinal Intussusceptions: CT Appearances and Identifications of a Causative Lead Point. RadioGraphics 26:733-744 (PMID: 16702451)
[2] Huang BY, Warshauer DM. (2003) Adult Intussusception: Diagnosis and Clinical Relevance. Radiologic Clinics of North America 41(6):1137-1151 (PMID: 14661662)
[3] Barussaud M, Regenet N, Briennon X, et al. (2006) Clinical spectrum and surgical approach of adult intussusceptions: a multicentric study. International Journal of Colorectal disease 21(8):834-839 (PMID: 15951987)
[4] Begos DG, Sandor A, Modlin IM. (1997) The diagnosis and management of adult intussusception. The American Journal of Surgery 173(2):88-94 (PMID: 9074370)
[5] Sundaram B, Miller CN, Cohan RH, et al. (2009) Can CT features be used to diagnose surgical adult bowel intussusceptions?. AJR 193:471-478 (PMID: 19620445)
[6] Gayer G, Zissin R, Apter S, Papa M, Hertz M. (2002) Pictorial review:adult intussusception-a CT diagnosis. The British Journal of radiology 75(890):185-190 (PMID: 11893645)
[7] Lindor RA, Bellolio MF, Sadosty AT, et al. (2012) Adult intussusceptions: presentation, management and outcomes of 148 patients. Journal of Emergency Medicine 43:1-6 (PMID: 22244289)
[8] Daneman A, Navarro O. (2003) Intussusception. Part 1: A review of diagnostic approaches. Pediatric Radiology 33:79-85 (PMID: 12557062)
Case information
| URL: | https://www.eurorad.org/case/13334 |
| DOI: | 10.1594/EURORAD/CASE.13334 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
Axial cross section
Axial cross section showing interposition of ileum (orange arrow) into ascending colon (blue arrow).
Figure 3
Coronal scan
Coronal scan showing interposition of the ileum (orange arrow) into ascending colon (green arrows)
Figure 4
Sagittal scan
Sagittal view showing intussusception of the ileum (orange arrow) into ascending colon (green arrows)
Figure 5
\"Target\" lesion
Axial cross section showing an ileum segment (orange arrow) within the lumen of the ascending colon (green arrows). Note the fat attenuation crescent corresponding to the ileal mesentery (red arrow).
Figure 6
Surgical specimen
Interpostition of ileum (star) into ascending colon (blue arrowhead) secondary to cecal mass (thin arrow). Appendix (green arrow).
Intestinal transit
Intestinal transit showing a filling defect in the cecum suggesting the existence of a mass (blue arrow).
Department of Radiology, Valladolid Clinical Hospital, Valladolid, Spain
Department of Radiology, Valladolid Clinical Hospital, Valladolid, Spain
Axial cross section
Axial cross section showing interposition of ileum (orange arrow) into ascending colon (blue arrow).
Department of Radiology, Valladolid Clinical Hospital, Valladolid, Spain
Department of Radiology, Valladolid Clinical Hospital, Valladolid, Spain
Coronal scan
Coronal scan showing interposition of the ileum (orange arrow) into ascending colon (green arrows)
Department of Radiology, Valladolid Clinical Hospital, Valladolid, Spain
Department of Radiology, Valladolid Clinical Hospital, Valladolid, Spain
Sagittal scan
Sagittal view showing intussusception of the ileum (orange arrow) into ascending colon (green arrows)
Department of Radiology, Valladolid Clinical Hospital, Valladolid, Spain
Department of Radiology, Valladolid Clinical Hospital, Valladolid, Spain
\"Target\" lesion
Axial cross section showing an ileum segment (orange arrow) within the lumen of the ascending colon (green arrows). Note the fat attenuation crescent corresponding to the ileal mesentery (red arrow).
Department of Radiology, Valladolid Clinical Hospital, Valladolid, Spain
Department of Radiology, Valladolid Clinical Hospital, Valladolid, Spain
Surgical specimen
Interpostition of ileum (star) into ascending colon (blue arrowhead) secondary to cecal mass (thin arrow). Appendix (green arrow).
Department of General Surgery, Valladolid Clinical Hospital, Valladolid, Spain
Department of General Surgery, Valladolid Clinical Hospital, Valladolid, Spain