DR JAIKISHOR JOTHIRAJ MD POST GRADUATE DEPT OF RADIODIAGNOSIS

DR JAIKISHOR JOTHIRAJ MD POST GRADUATE DEPT OF RADIODIAGNOSIS

YASHODAMMAL 70 YRS OD LADY had C/o diffuse lower abdominal pain 20 days h/o blood in stools 4 days h/o vomiting 2 days h/o burning micturation +ve h/o abdominal surgery 30 yrs back Not a k/c/o DM/HT/BA

O/E No guarding No rigidity No distention No blood in P/R AMOEBIC COLITIS??

USG TARGET SIGN +VE BOWEL with in BOWEL appearance PROBE tenderness + ve pseudo kidney sign +ve UGI ENDOSCOPY normal Chest x ray pa no free air under diaphragm X ray abdomen erect dilated small bowel,with multiple air fluid levels & gaseous distention of proximal colon CT well defined fat density [ 100 to 120 hu] lesions of size 4.2 3.8 cms noted within lumen of sigmoid colon with telescoping of sigmoid loops

Target Sign DDX TARGET SIGN 1.APPPENDICULAR MASS 2.LEIOMYOMA 3.MELANOMA RECTUM 4.LYMPHOMA 5.ENCEPHALOID CA Central hyperechoic region (C) surrounded by hypoechoic and homogeneous edge (bowel wall)

Cylindrical hyperechoic center (C) that continues from intestinal lumen and is surrounded on both sides by hypoechoic mesentary (M) Sandwich sign

PROXIMAL PORTION

DISTAL END Distal end

axr Absence of bowel gas in the area Rounded soft tissue mass Crescent of air at the apex of an intussusception Target sign

Where is the target sign? Created by gas trapped between two layers of intestinal wall

Where is the crescent sign? Created by gas surrounding invagination

COLONOSCOPY REPORT Globular mass seen in the lumen of the rectum which on inflation retracted back upto sigmoid Scope could not be passed further Rectal mucosa appears normal POLYPOIDAL MASS? LIPOMA INTUSSUSCEPTING from sigmoid rectum

DIAGNOSIS SIGMOID colon lipoma acting as a lead point for intussusception

Just as a refresher

What is IS? 1 portion of the small bowel invaginating into the distal portion of small bowel, pulled in by peristalasis Type of intussusception depends on segment of bowel that is involved Starting at the ileocolic junction ileocolic intussusception Intussusceptum =proximal portion Intussuscipen =distal portion

ETIOLOGY WEANING PERIOD VIRAL GASTRO ENTERITIS {rota,polio} INFLAMMATION & ENLARGEMENT OF LYMPHOID TISSUE PAEYER S PATCHES Neoplasam Gastro jejunal & naso jejunal feeding tubes 5 10% meckel s diverticulum,polyps,lymphomas,duplication

Classic Triad Colicky abdominal pain pulling knees up to abdomen Currant Jelly bloody stools Abdominal Mass sausage shaped Multiple studies have shown that classic triad is only present in 20 50% 70% found to have 2 sx 9% found to have 1 sx

Classification Intraluminal Intramural Extraluminal Primary Secondary Ileo colic Ileo ileo colic Colo colic Ileo ileal Gastro colic

Colocolic

OPERATIVE FINDINGS Intra abdominal adhesions Submucosal lipoma in sigmoid colon Rest of intra abdominal areas normal

In a nutshell Base your next move on CLINICAL SUSPICION IF LOW suspicion AXR if negative, unlikely to be IS IF MEDIUM suspicion AXR US if US negative, unlikely to be IS IF HIGH suspicion, you can skip AXR and proceed directly to US for confirmative CT contrast

Treatment 17% of IS spontaneously reduce 1 st NPO, IV fluids, NG tube 2 nd surgery consult Otherwise, tx by reduction enemas or surgery Reduction Enema Successful when flow moves into ileum Pt is under sedation Disadvantages missed lead points, higher recurrence rate, perforation, and radiation exposure But benefits outweigh risks less invasive than surgery, faster recovery Surgery Indications irreducible by enema, necrotic IS, age, long duration of sx, SBO, or clinical signs/sx of peritonitis or bowel infarction

Enema 3 types Pneumatic Hydrostatic Barium Succesful reduction disappearance of mass & flooding of air into the small bowel

Pneumatic Enema: Before and After

BARIUM ENEMA

risk Inducing /uncovering a pre existing perforation Tension pneumoperitoneum Respiratory & haemodynamic instability Hydrostatic enema rapid fluid shifts if isoosmolar concenteration not used Barium enema