CASE OF THE WEEK

A young 30 years female patient presents with acute left sided abdominal pain

With nausea and vomiting.

On examination Tachycardia Abdominal guarding with tenderness on the

left side.

lab investigation Blood picture was normal with normal LFTS

and RFTS.

On imaging , her CT abdomen reveals This specific appearance.

Intussusception

58 y/o male with no significant past medical history has a 3 day history of intermittent cramping abdominal pain, vomiting, and diarrhea.

Abdominal Radiograph

Erect Abdominal Radiograph

Barium Study

The Invagination or telescoping of a proximal segment of bowel (intussusceptum) into the lumen of a distal segment (intussuscipiens)

Intussusception

This can often result in an obstruction. The part that prolapses into the other is called the intussusceptum, and the part that receives it is called the intussuscipiens.

The invaginated segment is carried distally by peristalsis.

Mesnetery and vessels become involved with the intraluminal loop and are squeezed within the engulfing segment causing venous congestion.

Types: enteroenteric, enterocolic, and colocolic.

Pathophysiology

Pathogenesis, aetiology and prevalence Intussusception can be classified according

to location (small bowel or colon) or according to the underlying aetiology (neoplastic (benign or malignant), non-neoplastic or idiopathic).

Intussusception arises in the small bowel in two-thirds of cases. The aetiology of intussusception in the small bowel and the colon is quite different.

Most common in infants and children Accounts for 95% of all cases of

intussusception Ranks 2nd to appendicitis as a cause of

acute abdomen 90% of the cases in children are idiopathic Most common in children of 6 months to 2

years in age

Epidemiology (Children)

Rare in adults: accounts for 0.003% to 0.02% of all hospital admissions

Accounts for 1% of all bowel obstructions in adults

80-90% of cases have and underlying cause 65% are due to neoplasm

Epidemiology (Adults)

Location◦ Adults: ileoileal > ileocolic > colocolic◦ Children: ileocolic > ileoileal > colocolic

Epidemiology

Idiopathic (most common in children) Neoplasm

◦Benign (more common in small bowel) Polyp, Leiomyoma, Lipoma, Lymphoma, Adenoma of

appendix, Appendiceal stump granuloma

◦Malignant Primary (more common in colon) Metastatic (more common in small bowel)

Etiology

Postoperative (more common in small bowel)

Meckel’s diverticulum Colitis Many cases thought to be related to viral

gastroenteritis in children

Children:◦ Well nourished infant◦ Cramping abdominal pain◦ Poor feeding / Vomiting◦ Diarrhea ◦ A palpable, tender, sausage shaped mass in the

abdomen◦ Hx of abdominal surgery

History and Physical Examination

Adults◦ Intermittent pain◦ Nausea and vomiting ◦ Often red blood per rectum ◦ Often nonspecific complaints

CT is the most accurate detecting 78% of the cases.

Ultrasound is often used in children Barium studies are also very useful

Imaging

Abdominal Plain X ray

Abdominal films often show signs of small bowel obstruction

Erect films often show fluid levels in the small bowel

Free intraperitoneal gas

Barium Studies

Show a classic “coiled spring” appearance due to trapping of contrast between layers of bowel.

Ultrasound

Ultrasound: transverse scan shows a target sign

Ultrasound is today considered the imaging modality of choice for diagnosis and exclusion of intussusception due to its high accuracy and lack of radiation. A target-like mass, usually around 3 cm in diameter, confirms the diagnosis

53-year-old woman who had history of total gastrectomy due to advanced gastric cancer with retrograde jejunojejunal intussusception caused by adhesive band. Sonogram along longitudinal axis of intussusception shows typical “pseudokidney” sign

Intussusception can be confidently diagnosed on CT because of its virtually pathognomonic appearance.

It appears as a complex soft tissue mass, consisting of the outer intussuscipiens and the central intussusceptum.

There is often an eccentric area of fat density within the mass representing the intussuscepted mesenteric fat, and the mesenteric vessels are often visible within it

CT appearance

A rim of orally administered contrast medium is sometimes seen encircling the intussusceptum, representing coating of the opposing walls of the intussusceptum and the intussuscipiens

The intussusception will appear as a sausage-shaped mass when the CT beam is parallel to its longitudinal axis but will appear as a “target” mass when the beam is perpendicular to the longitudinal axis of the intussusception

CT

Target sign is also seen in CT.

Can also see a sausage shaped mass

Small bowel intussusception in a 51-year-old man with recurrent left lower quadrant pain. Contrast material–enhanced CT scan of the abdomen demonstrates the typical multilayered appearance of a small bowel intussusception. The intussusceptum (black arrowhead), with an accompanying complex of mesenteric fat and blood vessels (arrow), is surrounded by the thick-walled intussuscipiens (white arrowhead).

Differential diagnosis Intussusception has three main differential

diagnoses. These are acute gastroenteritis, Henoch–Schönlein purpura, and rectal prolapse.

Abdominal pain, vomiting, and stool with mucus and blood are present in acute gastroenteritis, but diarrhea is the leading symptom.

Rectal prolapse can be differentiated by projecting mucosa that can be felt in continuity with the perianal skin, whereas in intussusception the finger may pass indefinitely into the depth of sulcus. Henoch–Schönlein purpura presents the characteristic rash.

Air reduction is the treatment of choice for children and is successful 75-90% of the time

Contrast reduction was more frequently used a decade ago

Treatment (children)

Adults require surgical exploration and resection of the intussuscepted bowel loops

Reduction is not recommended in adults due to the risk of spreading/seeding malignant cells, potential perforation of the intussuscepted bowel, and venous embolization at the ulcerated mucosa area

Treatment (Adults)

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