May 1 2014 Fellow David Tang MD Faculty Milena Gould MD Case Presentation 61 year old White man Bloating and constipation alternating with diarrhea for 3 months No weight loss No rectal bleeding ID: 745607
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Slide1
Gastroenterology Grand Rounds
May 1, 2014Fellow: David Tang, M.D.Faculty: Milena Gould, M.D.Slide2
Case Presentation
61 year old White manBloating and constipation alternating with diarrhea for 3 months.No weight loss
No rectal bleeding
8/29/2012
Hgb
8.3
MCV
68
Ferritin
2.60
FIT
PositiveSlide3
Colonoscopy
12/14/2012
Polyp at 40 cmSlide4
Colonoscopy
12/14/2012
Mass at 45 cmSlide5
Colonoscopy
12/14/2012
Mass at 45 cmSlide6
Case Presentation
HistologyPolyp at 40 cm
Tubulovillous
adenoma
Mass at 45 cm
Invasive adenocarcinomaStaging CT scan showed mass in the descending colon and another large mass in the cecum.Slide7
Case Presentation
Patient refused referral to Medical Oncology until June 2013He continued to suffer from intermittent abdominal pain, bloating, and diarrhea
A repeat colonoscopy was performed to biopsy the
cecal
massSlide8
Colonoscopy
7/11/2013
Sigmoid Mass #1Slide9
Colonoscopy
7/11/2013
Sigmoid Mass #2Slide10
Colonoscopy
7/11/2013
Descending Colon MassSlide11
Colonoscopy
7/11/2013
“Ascending Colon Mass vs Extrinsic Compression”Slide12
Case Presentation
Four days after colonoscopy, patient presented to EC with constant severe abdominal camps and pain associated with nausea and vomitingSlide13Slide14
Cecal
mass
Terminal Ileum
Distal colon
Everted
cecal
wall
Courtesy of Dr.
Zarrin-KhamehSlide15
Diagnosis
Intussusception of the cecum into the descending colon due to cecal
adenocarinomaSlide16
Clinical Questions
What is the incidence of adult intussusception?What is the traditional understanding of the etiology of adult intussusception?How has CT changed our understanding of the etiology and natural history of adult intussusception?
Is there a role for endoscopy to treat adult intussusception?Slide17
Incidence of Adult Intussusception
Cross-sectional study from Glasgow, UK estimated an annual incidence of 2 – 3 cases per 100,000 (<0.1% hospital admissions)Intussusception accounts for ~ 1% of adult patients with bowel obstruction
Nalmpantidis
Ann
Gastroenterol
2012
Azar
Ann
Surg
1997Slide18
Etiology of Adult Intussusception
Retrospective review of 58 patients collected from 1964 – 1993 at Massachusetts General Hospital
Azar
Ann
Surg
1997Slide19
Etiology of Adult Intussusception
Azar
Ann
Surg
1997Slide20
Etiology of Adult Intussusception
Retrospective review of 22 cases of adult intussusception in Winnipeg, Canada hospital from 1989 – 2000.
Zubaidi
Dis Colon Rectum 2006Slide21
Etiology of Adult Intussusception
Zubaidi
Dis Colon Rectum 2006Slide22
Etiology of Adult Intussusception
Retrospective review of 44 cases of adult intussusception in a Chinese hospital from 2001 to 2008.
Wang World J
Gastroenterol
2006Slide23
Etiology of Adult Intussusception
Wang World J
Gastroenterol
2006Slide24
Etiology of Adult Intussusception
Azar
Ann
Surg
1997
Zubaidi Dis Colon Rectum
2006
Wang World J
Gastroenterol
2006
Eisen
J Am
Coll
Surg
1999
Colonic
Malignant
Idiopathic
N
Azar
et al.
24%
46%
1.7%
58
Zubaidi
et al.
27%
36%
13.6%
22
Wang et al.
20%
27%
9.1%
44
Eisen
et
al.
19%
44%
8%
27Slide25
Etiology of Adult Intussusception
Horton AJR 2008
Berger NEJM 2000
Crohn’s
disease
Celiac disease
Giardiasis
HIV
EndometriosisSlide26
Etiology of Adult Intussusception
Felix Am J
Surg
1976Slide27
Diagnosis of Adult Intussusception
Retrospective review of 33 adults with 41 cases of intussusception on CT.37 cases of small bowel involvement and 4 cases of colonic involvementAll 4 colonic cases had neoplastic lead point on follow up
29 cases (from 23 patients) of enteric involvement had non – neoplastic lead points
16 of 23 patients with idiopathic etiology
None of these patients had recurrent intussusception
Warshauer
Radiology 1999Slide28
Diagnosis of Adult Intussusception
Retrospective review of 37 patients with intussusception on CT and median 119 days of follow upOnly 6 patients (17%) required surgery25 of these patients with “self-limiting” intussusception
13 of these patients without intussusception on follow up imaging
Lvoff
Radiology 2003Slide29
Diagnosis of Adult Intussusception
Lvoff
Radiology 2003Slide30
Diagnosis of Adult Intussusception
Multivariate, stepwise, logistic regression analysis showed
that
intussusception
length
was the only variable independently predictive of outcome, with an odds ratio of 1.57 (
95
% CI: 1.17 – 2.11).
All 20 patients with intussusception length < 3.5 cm had self-limiting outcomes.
Lvoff
Radiology 2003Slide31
Diagnosis of Adult Intussusception
Retrospective review of 121 patients with 136 intussusceptions on
CT
88%
enteroenteric
intussusceptionsOnly 6% of intussusceptions required surgery2.5% of entroenteric intussusceptions treated with surgeryCompared with 45% of colonic intussusceptions treated with surgery
Lvoff
Radiology 2003Slide32
Role of Endoscopy
Kitamura GIE 1990
44 year old woman with repeated episodes of abdominal pain, diarrhea, and vomiting.
Barium enema showed a
lipoma
which was reduced with colonoscopy and later resected.Slide33
Role of Endoscopy
Idiopathic prolapse of ileal mucosa through ileocecal
valve mistaken for
cecal
mass on imaging and reduced with colonoscopy.
One out of 13 patients identified on retrospective review from 1981 – 1994 underwent successful colonoscopic polypectomy of
ileal
lipoma
with subsequent reduction.
Eu
Singapore Med J 1994
Begos
Am J
Surg
1997Slide34
Role of Endoscopy
Begos
Am J
Surg
1997Slide35
Role of Endoscopy
Brayton
Am J
Surg
1954Slide36
Thank You
Dr. Milena GouldDr. Neda
Zarrin-Khameh
Dr. Juan IbarraSlide37Slide38Slide39Slide40