Adult Intussusception: A Complication of Metastatic Melanoma or Primary Malignancy?

January 2013 Adult Intussusception: A Complication of Metastatic Melanoma or Primary Malignancy? Johanna Sheu, Harvard Medical School Year III 1

Agenda Menu of tests Definition/anatomy/classification Pediatrics and adults Pediatrics Clinical presentation, menu of tests Pediatric patients and imaging Adults Clinical presentation, menu of tests Adult patient and imaging 2

Menu of tests for imaging small and large bowel Common studies -Abdominal plain films -Barium studies -Abdominal CT Lesser used studies -Angiography -Radionuclide studies -Ultrasound -Abdominal MRI Lieberman s Interactive Tutorials in Radiology 4

Intussusception: definition A mass or lead point causes proximal bowel to telescope into the lumen of a distal segment of bowel through normal peristalsis. Intussusipiens ( recipient ) intussusceptum ( thumb ) Punnoose et al. JAMA 2012;307(6):628. 6

Intussusception: clinical relevance Abdominal mesentery containing vascular components becomes trapped between overlapping layers of bowel Compression of the vasculature may lead to bowel edema and necrosis Punnoose et al. JAMA 2012;307(6):628. 7

By location: Anatomy and Classification - entero-enteric: small bowel - colo-colic: large bowel - Ileo-colic: terminal ileum within ascending colon - Ileo-cecal: ileum is drawn into cecum 8

Pediatric Intussusception 95% of intussusception cases classic triad : cramping abdominal pain, bloody diarrhea, palpable tender mass Often idiopathic and thought to be due to viral infection with Peyer s patch hypertrophy Secondary causes: Meckel s diverticulum, intestinal polyp, intramural hematoma, enteric duplication, lipoma, etc. 10

Menu of tests: pediatric intussusception Common studies -Abdominal plain films -Barium studies -Abdominal CT Lesser used studies -Angiography -Radionuclide studies -Ultrasound -Abdominal MRI Lieberman s Interactive Tutorials in Radiology 11

Imaging in pediatrics: ultrasound Advantages: No radiation exposure Convenient and quick Add color doppler to detect lack of perfusion indicating ischemia Real-time frame of reference Disadvantages: Operator dependent Air in bowel has poor transmission 12

Patients 1 & 2: Intussusception on ultrasound Patient 1: Transverse view target sign or bull s eye Patient 2: Longitudinal view sandwich sign or psuedokidney John Radiol Clin North Am. 1999 Sep;37(5):995-1034 F: fat L: lymph node PathWest Laboratory medicine 14

Patients 3 & 4: Transverse ultrasound Patient 3 Small arrowhead denotes hyperechoic mesenteric fat target sign or bull s eye Patient 4 Ko et al. Eur Radiol 2007; 17:2411. Ko et al. Eur Radiol 2007; 17:2411. 15

Patients 5 & 6: Longitudinal ultrasound sandwich sign or psuedokidney Patient 5 Patient 6 Ko et al. Eur Radiol 2007; 17:2411. Ko et al. Eur Radiol 2007; 17:2411. 16

Children s Hopsital Boston Johanna Sheu, 2013 Patient 7: Pediatrics 24m old girl, presents with waxing and waning severe abdominal pain and refusing food. TRANSVERSE US 17

Treatment in pediatrics: air enema 1) Stable? Yes No Surgery 2) Evidence of bowel perforation or ischemia? No Yes Surgery Non-operative reduction: Air (preferred) or barium (only used in some institutions) enema 18

Patient 7: Pediatric Treatment After reduction under fluoroscopy, showing open loops of bowel SUPINE FLUOROSCOPY 19 Children s Hospital Boston

Adult Intussusception 5% of all intussusception cases Intussusception counts for 1-5% of bowel obstruction Non-specific symptoms: chronic colicky pain, nausea, vomiting, bleeding, constipation, palpable abdominal mass 21

Adult Intussusception: Causes Often secondary: 70% neoplasm benign (small intestine) and malignant (large intestine) Celiac: loss of tone, chronic dilatation IBD: chronic inflammation, enlarged lymph nodes Trauma Surgery Can be transient and not clinically significant 22 if detected only on CT scan

Menu of tests: adult intussusception Common studies -Abdominal plain films -Barium studies -Abdominal CT Lesser used studies -Angiography -Radionuclide studies -Ultrasound -Abdominal MRI Lieberman s Interactive Tutorials in Radiology 23

Additional imaging in adult intussusception Plain film small bowel obstruction, coil spring appearance of bowel MRI similar findings to CT Colonoscopy able to localize and directly visualize Ultrasound limited in adults by obesity and air in bowel lumen 24

Imaging in adults: CT Progression with time Baleato-Gonzalez S. Emerg Radiol 2012;19:89-101. 25

Our patient: Clinical presentation 80 year old woman with known metastatic melanoma (vertebral, lung) with 2-week history of intermittent right abdominal discomfort and loss of appetite. 27

Our patient: Intraluminal fat and vessels on CT C+ AXIAL CT 28 PACS, BIDMC

Our patient: Intraluminal fat and vessels on CT, labeled Mesenteric vessels and fat C+ AXIAL CT 29 PACS, BIDMC

Our patient: Intraluminal fat and vessels on CT C+ CORONAL CT 30 PACS, BIDMC

Our patient: Intraluminal fat and vessels on CT, labeled Intussusceptum Mesenteric vessels Intussusipiens C+ CORONAL CT 31 PACS, BIDMC

Treatment in adults: surgery Ileo-ileal intussusception with hemorrhagic infarction Albright et al. Can Fam Physician 2007 Feb;53(2):241-3. PathWest Laboratory medicine Surgical treatment often prevents any further recurrence 32

Our patient: conclusion Patient taken to surgery and underwent right colectomy. Pathology showed adenocarcinoma. Patient did well after surgery and returned to hospice care. 33

Summary Menu of tests Definition/anatomy/classification Pediatrics and adults Pediatrics Clinical presentation, menu of tests Pediatric patients and imaging Adults Clinical presentation, menu of tests Adult patient and imaging 34

References Marinis A, Yiallourour A, Samanides L, et al. Intussusception of the bowel in adults: A review. World J Gastroenterol 2009;15(4):407-411. Baleato-Gonzalez S, Vilanova JC, Garcia-Figueiras R, Juez IB, de Alegria AM. Intussusception in adults: what radiologists should know. Emerg Radiol 2012;19:89-101. Punnoose AR, Kasturia S, Golub RM. Intussusception. JAMA 2012;307(6):628. Ko HS, Schenk JP, Tröger J, Rohrschneider WK. Current radiological management of intussusception in children. Eur Radiol 2007; 17:2411. John SD. Trends in pediatric emergency imaging. Radiol Clin North Am. 1999 Sep;37(5):995-1034 PathWest Laboratory Medicine Diagnostic Imaging Pathways Acute Non-Traumatic Abominal Pain in Children Gov of West Aus Web. 29 Jan, 2013. Applegate, KE. Clinically Suspected Intussusception in Children: Evidence-Based Review and Self-Assessment Module. American Journal of Roentgenology, 2005;185(3):S175-S183 Albright MT, Grief SN, Carroll RE, Xu J. Ileoileal intussusception in an adult patient. Can Fam Physician. 2007 Feb;53(2):241-3. Gonda TA, Khan SUZ, Cheng J, Lewis SK, Rubin M, Green PHR. Association of Intussusception and Celiac Disease in Adults. Digestive Diseases and Sciences. 2010;55(10):2899-2903. 35

Acknowledgements Many thanks to: Elizabeth Asch, MD Michael Acord, MD Claire Odom BIDMC Radiology Department 36