Adult Intestinal Intussusception: Radiologic

Adult Intestinal Intussusception: Radiologic-Pathologic
Correlation
Poster No.:
C-2355
Congress:
ECR 2013
Type:
Educational Exhibit
Authors:
C. Rubio Hervás, A. Verón Sánchez, A. Díez Tascón, D.
Mollinedo, E. Canales Lachén, M. Marti; Madrid/ES
Keywords:
Obstruction / Occlusion, Metastases, Cancer, Surgery, Ultrasound,
Fluoroscopy, CT, Gastrointestinal tract, Emergency, Abdomen
DOI:
10.1594/ecr2013/C-2355
Any information contained in this pdf file is automatically generated from digital material
submitted to EPOS by third parties in the form of scientific presentations. References
to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in
any way constitute or imply ECR's endorsement, sponsorship or recommendation of the
third party, information, product or service. ECR is not responsible for the content of
these pages and does not make any representations regarding the content or accuracy
of material in this file.
As per copyright regulations, any unauthorised use of the material or parts thereof as
well as commercial reproduction or multiple distribution by any traditional or electronically
based reproduction/publication method ist strictly prohibited.
You agree to defend, indemnify, and hold ECR harmless from and against any and all
claims, damages, costs, and expenses, including attorneys' fees, arising from or related
to your use of these pages.
Please note: Links to movies, ppt slideshows and any other multimedia files are not
available in the pdf version of presentations.
www.myESR.org
Page 1 of 29
Learning objectives
Describing the key imaging features associated with adult intestinal intussusception. Also
discusses the CT findings that can help determining the appropriate treatment.
Background
Approximately 5% of all intussusceptions occur in adults, accounting for 1% of all bowel
obstructions. Intussusception refers to the invagination of a bowel loop with or without
mesenteric fat and mesenteric vessels (intussusceptum) into the lumen of a contiguous
portion of the immediately more distal bowel (intussuscipiens).
They are classified according to its location as: enteroenteric, ileocolic, ileocecal, or
colocolic. In adults, it can be further classified on the basis of whether a lead point is
present, which may pose a diagnostic challenge.
Intussusception without a lead point tends to be an incidental finding, transient, that
resolves spontaneusly, and do not require treatment. The majority of intussusceptions
without a lead point occurs in the small bowel and usually appears as a nonobstructing
segment, smaller in diameter and shorter than an intussusception with a lead point.
A lead point intussusception involving the small bowel is generally due to a benign
condition (lipoma, adenomatous polyp, Meckel diverticulum). More than one-half of large
bowel intussusceptions are associated with malignant lesions.
Symptoms related to an intestinal obstruction (prior history of episodic crampy abdominal
pain, nausea, vomiting) or symptoms related to a neoplasia (constipation, weight loss,
melena, palpable abdominal mass) suggests intussusception with a lead point.
The degree of bowel wall edema due to impaired circulation of the mesenteric vessels
may make a lead mass difficult to identify. CT appearances and identification of signs
(cross-sectional bowel diameter, intraluminal mass, free fluid, altered perfusion) can
provide a reliable radiologic indicator of an intussusception with a lead point.
We have retrospectively reviewed sixteen cases of adult intestinal invagination from our
database, identifying the signs leading to the diagnosis.
Page 2 of 29
Images for this section:
Fig. 1: Transient small bowel intussusception in a 27-year-old man with left
lower quadrant pain. Contrast-enhanced CT scan demostrates an entero-enteric
intussusception where we are able to identify a bowel loop which invaginates into the
lumen of a contiguous portion of bowel.
Page 3 of 29
Fig. 2: It is accompanied of mesenteric fat and blood vessels.
Page 4 of 29
Fig. 4: Anteroposterior radiography from single-contrast barium enema shows delayed
transit and increased intestinal secretion. No intussusception is observed.
Page 5 of 29
Fig. 3: A delayed view of the same small bowel loop shows transient proximal jejunum
intussusception, once passed duodeno-jejunal junction (angle of Treitz).
Page 6 of 29
Fig. 5: Enteroenteric intussusception in a 98-year-old woman with abdominal pain and
constipation. Contrast-enhanced CT scans of the abdomen shows a sausage-shaped
mass enveloping a fat-containing structure.
Page 7 of 29
Fig. 6: There is an abrupt change in caliber between the proximal dilated fluidfilled bowel loops and the collapsed distal ones. This change is due to enteroenteric
intussusception. Poorly differentiated renal medullary carcinoma acted like lead point of
the intussusception, although no tumor was identified in kidneys. An adjacent pathologic
lymph node is also observed.
Page 8 of 29
Imaging findings OR Procedure details
SMALL BOWEL INTUSSUSCEPTION
MECKEL DIVERTICULUM
The most common congenital anomaly of the gastrointestinal tract (2-3% of the
population). Complications: hemorrhage, small bowel obstruction and diverticulitis. It may
invaginate or invert into the lumen serving as a lead point for an ileoileal or ilecolic
intussusception.
At CT:
•
Central core of fat attenuation surrounded by a collar of soft-tissue
attenuation
LYMPHOMA
Primary lymphoma of the gastrointestinal tract is a common entity (20-40% of all
malignant tumors in the small bowel). Symptoms include: abdominal pain, weight loss,
small bowel obstruction and acute abdomen.
T-cell lymphomas are manifested as:
•
•
Ulcerated plaques
Fibrosis/strictures in the PROXIMAL small bowel
B-cell lymphomas are manifested as:
•
•
Annular or polypoid masses
In the DISTAL and TERMINAL ILEUM
At CT:
•
•
•
Mesenteric or retroperitoneal lymphadenopathy
Single or multiple masses, often with a large size, or nodular or diffuse
parietal thickness affecting a large small bowel segment (more often
terminal ileum)
Hypodense small bowel wall (differential diagnosis with inflammatory/
infectious pathology cursing with bowel wall edema)
Page 9 of 29
VENOUS MALFORMATIONS
They may manifest with bleeding, anemia or, if they form a mass, with intussusception.
The cecum is the most common site of venous malformations, followed by the right colon
and the jejunum. Patients are normally elderly with a history of cardiovascular disease.
In younger patients, look for atypical sites (small bowel).
INFLAMMATORY FIBROID POLYP
Also known as Vanek tumor (Vanek 1941). The stomach is the most common location,
followed by the small bowel. It can ulcerate and cause gastrointestinal bleeding or be a
cause of mechanical obstruction. Intussusception is rare. Malignancy is excepcional.
MALIGNANT FIBROUS HISTIOCYTOMA
It is the most common soft-tissue sarcoma late in life, occurring more frequently in the
extremities, trunk and retroperitoneum. Rare in visceral organs. Unusual cause of small
bowel intussusception.
MALIGNANT NEOPLASM
We have already said that a lead point intussusception involving the small bowel is
generally due to a benign condition and less often to a neoplasm. When malignant
neoplasm occurs, is usually a metastatic lesion, being the melanoma metastases the
most common metastatic lesions of both small and large bowel (in order of frequency:
small bowel > stomach > large bowel).
LARGE BOWEL INTUSSUSCEPTION
Identifying an underlying cause is not easy (except in lipoma).
More than one-half of them are associated with malignant lesions:
•
•
Adenocarcinoma > lymphoma > metastatic disease
Ileocolic/ileocecal or colocolic. Transient tumor-related colocolic
intussusception has been reported.
Page 10 of 29
Ileocolic-Ileocecal
The causes of ileocolic-ileocecal intussusception in adults are, in order of frequency,
adenocarcinoma, lymphoma and metasstasic disease. Melanoma metastases are the
most common metastatic lesions of both small and large bowel:
•
•
•
Found in 2-5% of patients
Small bowel > stomach > large bowel
Intussusception is very rare
Colocolic
Lipoma
•
•
•
•
•
•
The most common benign cause of colocolic intussusception
The most common benign tumors of the colon
Submucosal origin in 90% of cases
Usually solitary
DDx with mesentery and subserosal fat
"Asymptomatic"
Adenocarcinoma
•
•
The most common malignant cause of colonic intussusception
Symptomatic: bleeding, obstruction, palpable abdominal mass and
abdominal pain
Images for this section:
Page 11 of 29
Fig. 7: Ileocecal intussusception in a 34-year-old man with right lower quadrant
pain. There was a prior history of anemia. Contrast-enhanced CT shows ileocecal
intussusception caused by an inverted Meckel diverticulum, which appears as a central
core of fat surrounded by a collar of soft-tissue attenuation.
Page 12 of 29
Fig. 8: The anatomopathological diagnosis demonstrates ectopic pancreas with
adenomyomatosis in the inverted Meckel diverticulum head.
Page 13 of 29
Fig. 9: Ileo-colic intussusception in a 29-year-old man with abdominal pain. Contrastenhanced CT scan demonstrates an amorphous mass due to a diffuse and homogeneus
wall thickening of a large segment of bowel in the context of a large lymphoma of the
ileum. The mass is isoattenuating relative to the bowel wall edema, making differentiation
difficult.
Page 14 of 29
Fig. 10: Duodeno-duodenal intussusception in a 56-year-old man with accute hypogastric
pain. Contrast -enhanced CT scan of the abdomen shows the typical multilayered
appearance of small bowel intussusceptions.
Page 15 of 29
Fig. 11: There is a groove pancreatitis which may mimic a pancreatic head carcinoma.
The inflammation changes are located at the groove between the head of the pancreas,
the duodenum and the common bile duct.
Page 16 of 29
Fig. 12: Upper cross-sectional image shows intra and extrehepatic biliary dilatation (right)
and chronic pancreatitis changes including atrophy of the organ, main pancreatic duct
dilatation and calcification (left).
Page 17 of 29
Fig. 13: Ileoileal intussusception in a 75-year-old woman with metastatic melanoma
presenting accute left lower quadrant pain. Contrast material-enhanced CT scan of the
abdomen shows the typical multilayered appearance of small bowel intussusception. The
intussusceptum, with an accompanying complex of mesenteric fat and blood vessels,
is surrounded by thick-walled intussuscipiens. Note metastase actuating like lead mass
originating in the distal ileum.
Page 18 of 29
Fig. 14: Multiple large pedunculated polypoid masses in stomach and small bowel, and
rounded masses in mesenteric fat, retroperitoneum and celullar subcutaneus tissues are
also observed.
Page 19 of 29
Fig. 15: Note the presence of a heterogeneous mass in left lung.
Fig. 16: Ileo-colic intussusception secondary to adenocarcinoma in a 98-year-old woman.
Contrast-enhanced CT scans of the abdomen show the classic finding of a sausageshaped mass. Mesenteric fat and blood vessels are well visible accompanying the
intussusceptum loop.
Page 20 of 29
Fig. 17: Photograph of the gross surgical specimen shows the ileocolic intussusception.
Page 21 of 29
Fig. 18: Photograph of the gross surgical specimen shows the ileocolic intussusception.
Page 22 of 29
Fig. 19: Axial US scan in a 87-year-old woman with right lower quadrant pain. US scan
obtained near the apex shows multiple concentric rings (a hypoechoic surrounding a
hyperechoic one, which surrounds another hypoechoic ring). Hypoechoic outer ring is
formed by the everted limb of the intussusceptum and the intussuscipiens and the center
varies with the section level.
Page 23 of 29
Fig. 20: US scan obtained at the base of the intussusception shows the central limb of the
intussusceptum eccentrically surrounded by the hyperechoic mesentery, a situation that
produces the doughnut sign. An additional hypoechoic area which represents a lymph
node is also observed.
Page 24 of 29
Fig. 21: Doppler US scan show blood flow within the intussusceptum and mesentery.
Page 25 of 29
Fig. 22: Ileocolic intussusception secondary to adenocarcinoma in the previous patient.
Contrast-enhanced CT scans of the abdomen show the classic findings of a lead point
intussusception with invaginated mesenteric fat and vessels. The tumor serving as the
lead point originates at the cecum. Note the lymphadenophaty measured in Fig. 20.
Page 26 of 29
Fig. 23: Ileocolic intussusception secondary to adenoacarcinoma in a 79-year-old man.
Page 27 of 29
Fig. 24: Photograph of the gross specimen shows the invagination of the ileum into the
adjacent large bowel.
Page 28 of 29
Conclusion
•
•
•
The widespread application of CT in different clinical situations has
increased the level of detection of intussusceptions
Abdominal CT plays an important role in distinguishing between lead point
intussusception and non-lead point intussusception and has the potential of
reducing the prevalence of unnecessary surgery
Radiologists should be familiar with CT appearances and be well trained in
the identification of a causative lead point
References
1.
2.
3.
4.
5.
6.
7.
8.
Azar T, Berger DL. Adult intussusception. Ann Surg 1997; 226: 134-138.
Agha FP. Intussusception in adults. AJR 1986; 146: 527-531.
Kim YH, Blake MA, Harisinghani MG, et al. Adult intestinal intussusception:
CT appearances and identification of a causative lead point. Radiographics
2006; 26: 733-744.
Jain P, Heap SW. Intussusception of the small bowel discovered incidentally
by computed tomography. Australas Radiol 2006; 50: 171-174.
Knowles MC, Fishman EK, Kuhlman JE, Bayless TM. Transient
intussusception in Crohn's disease: CT evaluation. Radiology 1989; 170:
814.
Lvoff N, Breiman RS, Coakley FV, Lu Y, Warren RS. Distinghuishing
features of self-limiting adult small-bowel intussusception identified at CT.
Radiology 2003; 227: 68-72.
Levy AD, Hobbs CM. From the archives of the AFIP: Meckel diverticulum
- radiologic features with pathologic correlation. RadioGraphics 2004; 24:
565-587.
Kanoh T, Shirai Y, Wakai T, Hatakeyama K. Malignant fibrous histiocytoma
metastases to the small intestine and colon presenting an intussusception.
Am J Gastroenterol 1998; 93: 2594-2595.
Personal Information
Page 29 of 29