ADULT BOWEL INTUSSUSCEPTIONS: RADIOLOGY - PowerPoint Presentation

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ADULT BOWEL INTUSSUSCEPTIONS: RADIOLOGYAPPEARANCE AND IDENTIFICATION OF A CAUSATIVE LEAD POINT

N. MEKKI, R. KHARRAT, S. BOURKHIS, R. BEN NACEUR, F. BEN AMARA, N. MNIF.

CHARLE NICOLLE’S HOSPITAL, TUNIS, TUNISIA

Slide2

Introduction:Intussusception in adults is an unusual cause of bowel obstruction:

1%

of all bowel obstructions.

5 % of all intussusceptions.

80-90 %: due to an

underlying pathology

.

The

growing use of computed tomography (

CT

) and magnetic resonance imaging (

MRI

) has led to increased detection of intussusceptions

as

mostly unsuspected clinically, presented with non-specific abdominal pain.

Slide3

Objectives :

To describe the characteristic radiologic features of

intussusception

according to location.

To illustrate pathologies which cause intussusceptions.

To correlate the different features with the pathologic findings.

Slide4

Materials and methods : We made a retrospective study, over 1-year period (2011).

6 cases of adult bowel intussusceptions:

Sex ratio: 4 men/ 2 women.

Age : vary from 21 to 60 years, mean age: 38 years.

Explorations:

5 patients was explored by

abdominal enhanced CT examination General Electric (GE) 16 slices

.

One patient was explored by

MRI GE 1.5 Tesla .

Slide5

RESULTS:Clinical

presentation

was

non

specific

for all patients: abdominal pain+++

Radiology

detect:4 ileo ileal intessusception in 3 patients: 2 were in the same one.1 ileo coecal intessusception.1 colo colic intessusception in the transverse colon.1 colo rectal intessuscetion.

ETIOGIES

With

lead

point:

83.4%

Without

lead

point:

16.6%

Neoplastic

Non

neoplstic

1 case :

Post

operative

intessusception

.

Malignant

Benign

1 case :

Crhon’s

disease

Primary

: 2cases:

Secondary

: 1

case:

Metastasis

of

renal

adeno

carcinoma

1 case :

Lipoma

Rectal

adeno

carcinoma

Small

bowel

stromal

tumor

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Case N° 1: A.H. is a 36 year

old

man

who

consult

for

gastro

intestinal bleeding and anemia, contrast enhanced abdominal CT scan was made to identify the cause of hemorrhagia and to search if there is an active bleeding.2

1

RESULTS:

2

Axial slices of CT scan without (

1

) and with contrast enhancement (

2

).

They demonstrate the typical multilayered appearance of a small bowel

intussusception

in the left

hypochondrium

.

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Multiplanar reconstructions: sagittal

and coronal help a lot to see the sausage of the

ileo

ileal

intessusception

.

Sag

Sag Contrast-enhanced CT scan showed invaginated mesenteric fat and vessels . Sag

Sag

RESULTS:

Coro

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At laparotomy, the small bowel intussusception

was confirmed and histology showed the lead point to be a

stromal

tumor.

Coro

Ax

At

the top of the intessusception, we notice a round lesion that enhances heterogeneously after

contrast

injection

( ),

these

one

was

confirmed

by

peroperative

constatation .

Sag

RESULTS:

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Case N°2: R.S. is a 27 Year

old

men

who

was

admitted

in the emergency for abdominal

stab wounds, he was explored by surgery for peritoneal effusion. He was controlled after 10 days by CT without contrast enhancement.

CT

showed

the

target

aspect of

loops

in 2

differnt

sites in relation

with

2

small

bowel

intessusceptions

: the first

exist

under

the

liver

and the second

is

pelvic

.

RESULTS:

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Notice in

this

recontructed

images the

sausage

aspect

Intessusceptions

in this cases were taken as transient

because

the patient

was

asymptomatic

.

Another

control

after

2

weeks

showed

their

persistance,

surgery

did not found a lead point. The final diagnosis

was

post

operative

intessusceptions

.

RESULTS:

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Case N°3: M.A. is a 30 years

old

woman

operated

for

bilateral

kidney adenocarcinoma (radical right nephrectomy and left lumpectomy) consulting for non specific abdominal pain.Enhanced CT examination shows ileo ileal intessusception in the right iliac

fossa

.

RESULTS:

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We

notice the

presence

at

the distal portion of the

intessuceptum

, of an

oval

lesion ( ) that is enhanced by the contrast, it may be the causative lead point. The surgery and the histology find the underlying

pathology

to

be

a

bowel

metastasis

of a

renal

adeno

carcinoma

in the last

ileal loop

.

RESULTS:

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: cortico medullary

hypodense

range in the

upper

pole of the

left

kidney

suggestive of

tumor recurrence.CT shows also other lesions suggestive of metastasis : Intra peritoneal effusion

:

Osteolysis

of the left iliac wing suggestive of to metastases.

RESULTS:

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Case N°4: G.K. is a 21 year

old

men

followed

for

crhon’s

disease

since 6 months, he consult for abdominal pain, he was explored by MRI:CORO SSFSE MRI showed an important inflammatory thickening of the distal ileum heaving a look like tumor with intense heterogeneous enhancement after contrast injectionAX T1 GADORESULTS:

CORO T1

GADO

Small bowel

opacification

showed a masse in the

ileocecal

junction

CORO SSFSE

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SAG T1 GADO Notice the intestinal expansion upstream of the thickening.

Endoscopy

showed an inflammatory

ileo

cecal

valve which is prolapsed in the

caecum

, it showed also ulcerated terminal ileitis. The diagnosis was intessusception on an acute episode of crhon’s disease.RESULTS:SAG T1 GADOCORO T1 GADO The sagittal and coronal sections showed intussusception of the ileocecal valve into the caecum ( ) .

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Case N°5: M.H. is a 60 year

old

men

who

consult

in the emergency for abdominal pain

with

acute

bowel obstruction.RESULTS: CT scan showed the image of bowel-within

-

bowel

in the pelvis

clearly

visible on the axial and sagittal, relevant to a colo rectal

intessusception

( ).

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sag

Ax

Coro

Coro

The

surgery

confirm CT findings and histolo!gy showed

the

lead

point to

be

an

infiltrating

adeno

carcinoma

of the rectum.

RESULTS:

At

the top of the

sausage

,

we

notice an irregular stenosing mass with spontaneous

isoattenuating relative to rectal

wall

which

enhances

heterogeneously

after

contrast

injection .

we

notice

also

a densification of the

mesenteric

fat

surrouding

the rectum

with

lymphadenopathies

.

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Case N°6: M.H. is a 50 years

old

woman

who

was

treated for degenerated colic polyp, CT was made to control because of non specific abdominal pain: RESULTS:

Contrast

enhanced

CT scan

showed

a colo

colic

intessusception

( ) in the transverse colon

occuping

the

epigastrium

and the

left

hypochondrium

.

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CT showed in the tip of the

intussusception

an oval

hypodense

mass heaving spontaneously an homogeneous fat density without contrast enhancement, it is characteristic of a

lipoma

.

Surgery

confirmed the large bowel intessusception Histology confirmed the lead point to be a lipoma.RESULTS:

Slide20

Definition

:

Intussusception

is

a

progressive

invagination

of a bowel loop with its

mesentery and mesenteric vessels M (intussusceptum) into the lumen of a contiguous portion of bowel (intussuscipiens). It is the results of abnormal peristalsis producing unequal longitudinal forces in the intestinal wall. M

It

may

be

caused

by a mass

pulled forward by normal peristalsis

or by

functional

disturbances

.

Discussion:

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Clinical Presentation:

Symptoms are often chronic: several weeks to months, may be occasionally acute, it

may

be

related to the lead point.

Unlike children, the most common symptoms of

intussusception

in adult are non specific: Abdominal pain, nausea and vomiting +++Less frequently: constipation, fever, weight loss, diarrhea;It is often asymptomatic, especially in chronic invaginations or without leadpoint.Physical examination is often unremarkable, sometimes note palpable mass.Discussion:

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Classification:Intussusceptions are classified according to :

Location:

Small or large bowel

:

more frequent in the small bowel (2/3)than in the colon(1/3).

4 different locations:

Entero enteric

:

confined to the small Bowel. Colo colic:linvolving the large bowel only. Ileo colic: defined as the prolapse of the terminal ileum within the ascending colon.Ileo cecal: the ileo-cecal valve is the leading point of the Intussusception.With

underlying

pathology

: 80-90%:

Neoplastic

: 65%

Benign

Malignant

Non-

neoplastic

: 15-25%

Idiopathic

:10%:

-It tends to be

allmost

transient.

Causes

Discussion:

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Etiologies: in the colon:

the most common underlying

malignant lesions

in the colon: are

primary

malignant

tumors

: adenocarcinoma and lymphoma.Benign lesions : 30% lipoma, leiomyoma, adenomatous polyp, endometriosis and previous anastomosis. Idiopathic intussusception occurs less often than in the small bowel: 10%

Intussusception

in the large bowel is more likely to have a malignant etiology :

50–60%

Discussion:

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Etiologies: in the small bowel

Benign lesions:

65%

benign

neoplasms

:

lipoma

,

leiomyoma, haemangioma, neurofibroma, following abdominal surgery: adhesions,anastomosis,Meckel’s diverticulum, lymphoid hyperplasia and adenitis,Traumatism,coeliac disease, intestinal duplication

Crohn’s

disease

Malignant

lesions

:

15%

:

most often

metastatic

:

Melanoma+++

Idiopathic

intussusception

:

20%

Discussion:

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Radiological findings:

CT constitute the main imaging modality because of its virtually

pathognomonic

appearance:

bowel

-

within

-

bowel: 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. the mesenteric vessels are often visible within it.Discussion:

Slide26

Radiological findings:

When the CT beam is parallel to its longitudinal axis of

the

intussusc

eption

,

it

appears as a sausage-shaped mass.Sometimes as reniform or “pseudokidney” mass: it is due to edema, mural thickening, and vascular compromise.When the beam is perpendicular to the longitudinal axis, it appear as a ‘‘target’’ mass. Discussion:

Slide27

Radiological findings:

CT examination allow to:

Detect and confirm the diagnosis of

intessusception

.

Show the exact location: small or large bowel.

Appreciate the viability of

invaginated

loops.

Distinguish between Intussusception without a lead point: no signs of proximal bowel obstruction, target-like or sausage-shaped mass, layering effect.Intussusception with a lead point: signs of bowel obstruction, bowel wall edema with loss of the classic three-layer appearance due to impaired mesenteric circulation and demonstration of the lead mass. CT help reducing the number of unnecessary surgical interventions.Discussion:

Slide28

Radiological findings:Intessusception

with

an

underlying

lead

point

Suspected

by the

epidemiological data( age+++, medical history) and the clinical presentation.Ct scan find a mass in addition to the intussusception outlined distal to the tapered lumen of the intussusceptum.Discussion:

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Radiological findings: Intessusception

with

an

underlying

lead

point

The mass’s type is established by the study of its

spontanous density and enhancement: for example:Lipoma: fat density wihout containing blood vessels to be distinguished from mesenteric fat and without enhancement.Other malignant

tumors

(

primary

or

metastatic

):

tissular

density

with

heterogenous

enhancement

.

Neoplastic

lead point VS Non-neoplastic one:significantly longer significantly larger diameter significantly more proximal dilatation of small bowel downstream.Discussion:

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Radiological findings: Transcient intessusception

:

More

frequent

in the

small

bowel

than in the colonIt is most frequently detected incidentally and is presumed to be innocuous.Reported in adults with:Celiac disease Crohn diseaseDiscussion:

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Radiological findings:Magnetic

Resonance

Imaging (MRI)

Recent developments in MRI with ultrafast

multiplanar

techniques now allow for rapid evaluation of bowel obstruction.

The

multiplanar

HASTE (half-

fourier single shot turbo spin echo): SSFSE is particularly useful in the diagnosis of intussusception. The high contrast resolution between the increased signal of the trapped intraluminal fluid and the intermediate to low signal of the bowel wall can clearly demonstrate the pathology.Discussion:

Slide32

TreatmentThere is no universal agreement upon the correct treatment of adult

intussusception

,

The surgery decision is based on:

The epidemiological data: age, medical history ..

The

clinical

presentation

: acute abdominal pain, bowel obstruction, digestive hemorrhagia...The imaging findings: if a lead point is found or not,If there is ischemic bowel signs:The type of intervention depends essentially on the intraoperative findings.Discussion:

Slide33

Conclusion:Intussusception

in adults is an infrequent cause of

intestinal obstruction.

Preoperative diagnosis is difficult as symptoms can be

intermittent and long standing.

More frequent use of computed tomography in undiagnosed abdominal pain increases the pick up

rates.