American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Ileocolic intussusception secondary to gastrointestinal stromal tumor in a 61-year-old: a case report Abstract Intussusception is a common emergency in patients age of 3 months to 5 years. In adults, the diagnosis is infrequent but must be considered in the clinical setting of abdominal pain and vomiting. We present a case of a 61-year-old woman presenting with epigastric abdominal pain and vomiting, diagnosed with intussusception secondary to gastrointestinal stromal tumor. Serial bedside ultrasound examinations uncovered the diagnosis of intussusception, confirmed by computed tomographic scan during a paroxysm of pain. Intussusception has a much higher predilection for neoplasms in adults, with a high morbidity and mortality, so early recognition is critical in improving patient outcomes. Intussusception is the internal prolapse of intestine into the distal bowel. Traditionally, a mass or “lead point” is pulled distally by normal peristalsis. Patients generally present with vomiting and paroxysms of moderate to severe pain, first occurring in short and infrequent intervals. The presentation often appears nonsurgical and can easily be misdiagnosed as gastroenteritis. Gone unrecognized, compressive bowel ischemia and peritonitis can be fatal complications. A 61-year-old woman with a medical history significant for hyperlipidemia presented to the emergency department with vomiting and epigastric pain. Symptom onset was approximately 24 hours before arrival. She had 2 similar episodes earlier in the month, which resolved spontaneously. On presentation, she was hemodynamically stable (vital signs: blood pressure, 114/78 mm Hg; heart rate, 75 beats per minute; respiratory rate, 15 breaths per minute; temperature, 36.7°C; and pulse oximetry, 97%). She initially refused pain medications. Focused bedside sonography revealed gallstones without evidence of cholecystitis. Later, the patient’s vomiting persisted, and her abdominal pain had increased, migrating to the right lower quadrant. Repeated abdominal examinations confirmed increased tenderness in the right lower segment. The ultrasound was repeated but in the right lower quadrant, revealing concentric loops of bowel (Fig. 1) with a hyperechoic focus. Our differential diagnosis included intussusception and appendicitis with abscess. A computed tomography (CT) of the abdomen and pelvis with oral and intravenous contrast confirmed ileocolic intussusception (Fig. 2) corresponding to the abnormal bowel pattern noted on ultrasound. A partially calcified mass was identified as the presumptive lead point and concerning for malignancy. The patient was admitted to the surgical service and underwent laparoscopic ileocolic resection with primary anastomosis of the ileum to the ascending colon. Malignancy was confirmed, producing a final diagnosis of gastrointestinal stromal tumor (GIST) within the
terminal ileum (grade, T2N0Mx). The patient had a successful recovery postoperatively and was discharged on hospital day 4. Intussusception is a rare clinical entity in adults, only representing 5% of total cases of intussusception. In adults, symptoms can range from hours to weeks, with abdominal pain as the most common symptom [1]. Adult intussusceptions differ from pediatrics as they are much more likely (90%-95%) to have an underlying trigger or lead point. Malignant lesions account for 25% of small bowel and 50% of large bowel intussusceptions [1]. Mortality of intussusception is based largely on the etiology of the lead point and not the intussusception itself. For benign lesions, mortality is 8.7% but increases sharply to 52.4% for malignant lesions [2]. Several imaging modalities are available for the diagnosis of intussusception with varying diagnostic accuracy. In 2 retrospective case reviews, ultrasound was found to have a diagnostic accuracy of 60% [3] and 64% [1], increasing to 91% of patients with a palpable abdominal mass. The ultrasonographic findings in the transverse plane are that of a “target” mass with an outer hypoechoic rim and a central area of increased echogenicity. The longitudinal plane demonstrates alternating hypoechoic and hyperechoic layers resembling a “trident,” whereas imaging obliquely often demonstrates the “pseudokidney,” sign where the edematous wall mimics the hypoechoic renal cortex, and the hyperechoic intussusception mimics renal sinus fat [4,5]. The “target” sign is found in intussusception but can also be seen with other abdominal pathology. A more accurate “crescent-in-doughnut” sign (an even, outer hypoechoic rim with a central hyperechoic crescent) has been described [6,7].
Fig. 1. Transabdominal imaging of the right lower quadrant, demonstrating hyperechoic central focus with concentric loops of bowel.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Gelabert C, et al, Ileocolic intussusception secondary to gastrointestinal stromal tumor in a 61-year-old: a case report, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.03.037
2
C. Gelabert et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
adequacy of resection, tumor size, mitotic activity, and location within the small bowel, with small bowel having worse prognosis [13]. Abdominal pain continues to be a diagnostic challenge for emergency physicians because of the wide differential diagnoses. Patients with intussusception may present with signs and symptoms consistent with bowel obstruction only as the intussusception incarcerates. Given that intussusception has a much higher predilection for neoplasms in adults, with a high morbidity and mortality, early recognition is critical in improving patient outcomes.
Christopher Gelabert MD Jose Torradas MD Mathew Nelson DO Department of Emergency Medicine North Shore University Hospital Manhasset, NY 11030 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.03.037
References Fig. 2. Coronal image of CT abdomen depicting intussusception in right lower quadrant with tumor lead point.
Computed tomography is considered the most sensitive radiologic method to confirm intussusception with the reported diagnostic accuracy of 58% to 100% [1-3,5]. The characteristic features on CT scan include an inhomogeneous “target” or “sausage-shaped” soft tissue mass with layering effect. The presence of a lead point, the configuration of the lead mass, the degree of wall edema, and amount of invaginated mesenteric fat affect the appearance of the intussusception both on ultrasound and CT [8]. Intussusception is a very rare presentation of GIST tumors, as they tend to grow extraluminal [9]. They account for less than 3% of all gastrointestinal malignant neoplasms and only 20% of enteric neoplasms. Only 25% of GIST tumors are found in the ileum and are frequently incidental discoveries on endoscopy or CT for other purposes [10]. Treatment of intussusception in the adult population is most often surgical resection without attempting reduction [11]. Patients with ileocolic, ileocecal, and colocolic intussusceptions or older than the age of 60 years should obtain formal resections with appropriate oncologic techniques, with the construction of a primary anastomosis between healthy and viable tissue [11,12]. Prognosis depends on
[1] Chang C, Chen Y, Chen Y, Lin C, Yen H, Lou H. Adult intussusception in Asians: clinical presentations, diagnosis, and treatment. J Gastroenterol Hepatol 2007:1767–71. [2] Azar T, Berger DL. Adult intussusception. Ann Surg 1997;226(2):134–8. [3] Wang N, Cui X, Liu Y, Long J, Xu Y, Guo R, et al. Adult intussusception: a retrospective review of 41 cases. World J Gastroenterol 2009;15(26):3303–8. [4] Huang B, Warshauer DM. Adult intussusception: diagnosis and clinical relevance. Radiol Clin N Am 2003:1137–51. [5] Choi S, Han J, Kim S, Lee J, Kim Y, An S, et al. Intussusception in adults: from stomach to rectum. Am J Radiol 2004;183:691–8. [6] Tiao M, Wan Y, Ng S, Ko SF, Lee TY, Chen MC, et al. Sonographic features of smallbowel intussusception in pediatric patients. Acad Emerg Med 2001;8:368–73. [7] Del-Pozo G, Albillos J, Tejedor D. Intussusception: US findings with pathologic correlation—the crescent-in-doughnut sign. Radiology 1996;199:688–92. [8] Kim YH, Blake MA, Harsinghani MG, Archer-Arroyo K, Hahn PF, Pitman MB, et al. Adult intestinal intussusception: CT appearances and identification of a causative lead point. RadioGraphics 2006;26:733–44. [9] Gupta A, Gupta S, Tandon A, Kotru M, Kumar S. Gastrointestinal stromal tumor causing ileo-ileal intussusception in an adult patient: a rare presentation with review of literature. Pan Afr Med J 2011;8:29–34. [10] Miettinen M, Lasota J. Gastrointestinal stromal tumors—definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis. Virchows Arch 2001;438(1):1–12. [11] Begos D, Sandor A, Modlin I. The diagnosis and management of adult intussusception. Am J Surg 1997;173(2):88–94. [12] Eisen L, Cunningham J, Aufses A. Intussusception in adults: institutional review. J Am Coll Surg 1999;188(4):390–5. [13] DeMatteo R, Lewis JJ, Leung D, Mudan SS, Woodruff JM, Brennan MF. Two hundred gastrointestinal stromal tumors recurrence patterns and prognostic factors for survival. Ann Surg 2000;231(1):51–8.
Please cite this article as: Gelabert C, et al, Ileocolic intussusception secondary to gastrointestinal stromal tumor in a 61-year-old: a case report, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.03.037
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Ileocolic intussusception secondary to gastrointestinal stromal tumor in a 61-year-old: a case report Abstract Intussusception is a common emergency in patients age of 3 months to 5 years. In adults, the diagnosis is infrequent but must be considered in the clinical setting of abdominal pain and vomiting. We present a case of a 61-year-old woman presenting with epigastric abdominal pain and vomiting, diagnosed with intussusception secondary to gastrointestinal stromal tumor. Serial bedside ultrasound examinations uncovered the diagnosis of intussusception, confirmed by computed tomographic scan during a paroxysm of pain. Intussusception has a much higher predilection for neoplasms in adults, with a high morbidity and mortality, so early recognition is critical in improving patient outcomes. Intussusception is the internal prolapse of intestine into the distal bowel. Traditionally, a mass or “lead point” is pulled distally by normal peristalsis. Patients generally present with vomiting and paroxysms of moderate to severe pain, first occurring in short and infrequent intervals. The presentation often appears nonsurgical and can easily be misdiagnosed as gastroenteritis. Gone unrecognized, compressive bowel ischemia and peritonitis can be fatal complications. A 61-year-old woman with a medical history significant for hyperlipidemia presented to the emergency department with vomiting and epigastric pain. Symptom onset was approximately 24 hours before arrival. She had 2 similar episodes earlier in the month, which resolved spontaneously. On presentation, she was hemodynamically stable (vital signs: blood pressure, 114/78 mm Hg; heart rate, 75 beats per minute; respiratory rate, 15 breaths per minute; temperature, 36.7°C; and pulse oximetry, 97%). She initially refused pain medications. Focused bedside sonography revealed gallstones without evidence of cholecystitis. Later, the patient’s vomiting persisted, and her abdominal pain had increased, migrating to the right lower quadrant. Repeated abdominal examinations confirmed increased tenderness in the right lower segment. The ultrasound was repeated but in the right lower quadrant, revealing concentric loops of bowel (Fig. 1) with a hyperechoic focus. Our differential diagnosis included intussusception and appendicitis with abscess. A computed tomography (CT) of the abdomen and pelvis with oral and intravenous contrast confirmed ileocolic intussusception (Fig. 2) corresponding to the abnormal bowel pattern noted on ultrasound. A partially calcified mass was identified as the presumptive lead point and concerning for malignancy. The patient was admitted to the surgical service and underwent laparoscopic ileocolic resection with primary anastomosis of the ileum to the ascending colon. Malignancy was confirmed, producing a final diagnosis of gastrointestinal stromal tumor (GIST) within the
terminal ileum (grade, T2N0Mx). The patient had a successful recovery postoperatively and was discharged on hospital day 4. Intussusception is a rare clinical entity in adults, only representing 5% of total cases of intussusception. In adults, symptoms can range from hours to weeks, with abdominal pain as the most common symptom [1]. Adult intussusceptions differ from pediatrics as they are much more likely (90%-95%) to have an underlying trigger or lead point. Malignant lesions account for 25% of small bowel and 50% of large bowel intussusceptions [1]. Mortality of intussusception is based largely on the etiology of the lead point and not the intussusception itself. For benign lesions, mortality is 8.7% but increases sharply to 52.4% for malignant lesions [2]. Several imaging modalities are available for the diagnosis of intussusception with varying diagnostic accuracy. In 2 retrospective case reviews, ultrasound was found to have a diagnostic accuracy of 60% [3] and 64% [1], increasing to 91% of patients with a palpable abdominal mass. The ultrasonographic findings in the transverse plane are that of a “target” mass with an outer hypoechoic rim and a central area of increased echogenicity. The longitudinal plane demonstrates alternating hypoechoic and hyperechoic layers resembling a “trident,” whereas imaging obliquely often demonstrates the “pseudokidney,” sign where the edematous wall mimics the hypoechoic renal cortex, and the hyperechoic intussusception mimics renal sinus fat [4,5]. The “target” sign is found in intussusception but can also be seen with other abdominal pathology. A more accurate “crescent-in-doughnut” sign (an even, outer hypoechoic rim with a central hyperechoic crescent) has been described [6,7].
Fig. 1. Transabdominal imaging of the right lower quadrant, demonstrating hyperechoic central focus with concentric loops of bowel.
0735-6757/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Gelabert C, et al, Ileocolic intussusception secondary to gastrointestinal stromal tumor in a 61-year-old: a case report, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.03.037
2
C. Gelabert et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
adequacy of resection, tumor size, mitotic activity, and location within the small bowel, with small bowel having worse prognosis [13]. Abdominal pain continues to be a diagnostic challenge for emergency physicians because of the wide differential diagnoses. Patients with intussusception may present with signs and symptoms consistent with bowel obstruction only as the intussusception incarcerates. Given that intussusception has a much higher predilection for neoplasms in adults, with a high morbidity and mortality, early recognition is critical in improving patient outcomes.
Christopher Gelabert MD Jose Torradas MD Mathew Nelson DO Department of Emergency Medicine North Shore University Hospital Manhasset, NY 11030 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.03.037
References Fig. 2. Coronal image of CT abdomen depicting intussusception in right lower quadrant with tumor lead point.
Computed tomography is considered the most sensitive radiologic method to confirm intussusception with the reported diagnostic accuracy of 58% to 100% [1-3,5]. The characteristic features on CT scan include an inhomogeneous “target” or “sausage-shaped” soft tissue mass with layering effect. The presence of a lead point, the configuration of the lead mass, the degree of wall edema, and amount of invaginated mesenteric fat affect the appearance of the intussusception both on ultrasound and CT [8]. Intussusception is a very rare presentation of GIST tumors, as they tend to grow extraluminal [9]. They account for less than 3% of all gastrointestinal malignant neoplasms and only 20% of enteric neoplasms. Only 25% of GIST tumors are found in the ileum and are frequently incidental discoveries on endoscopy or CT for other purposes [10]. Treatment of intussusception in the adult population is most often surgical resection without attempting reduction [11]. Patients with ileocolic, ileocecal, and colocolic intussusceptions or older than the age of 60 years should obtain formal resections with appropriate oncologic techniques, with the construction of a primary anastomosis between healthy and viable tissue [11,12]. Prognosis depends on
[1] Chang C, Chen Y, Chen Y, Lin C, Yen H, Lou H. Adult intussusception in Asians: clinical presentations, diagnosis, and treatment. J Gastroenterol Hepatol 2007:1767–71. [2] Azar T, Berger DL. Adult intussusception. Ann Surg 1997;226(2):134–8. [3] Wang N, Cui X, Liu Y, Long J, Xu Y, Guo R, et al. Adult intussusception: a retrospective review of 41 cases. World J Gastroenterol 2009;15(26):3303–8. [4] Huang B, Warshauer DM. Adult intussusception: diagnosis and clinical relevance. Radiol Clin N Am 2003:1137–51. [5] Choi S, Han J, Kim S, Lee J, Kim Y, An S, et al. Intussusception in adults: from stomach to rectum. Am J Radiol 2004;183:691–8. [6] Tiao M, Wan Y, Ng S, Ko SF, Lee TY, Chen MC, et al. Sonographic features of smallbowel intussusception in pediatric patients. Acad Emerg Med 2001;8:368–73. [7] Del-Pozo G, Albillos J, Tejedor D. Intussusception: US findings with pathologic correlation—the crescent-in-doughnut sign. Radiology 1996;199:688–92. [8] Kim YH, Blake MA, Harsinghani MG, Archer-Arroyo K, Hahn PF, Pitman MB, et al. Adult intestinal intussusception: CT appearances and identification of a causative lead point. RadioGraphics 2006;26:733–44. [9] Gupta A, Gupta S, Tandon A, Kotru M, Kumar S. Gastrointestinal stromal tumor causing ileo-ileal intussusception in an adult patient: a rare presentation with review of literature. Pan Afr Med J 2011;8:29–34. [10] Miettinen M, Lasota J. Gastrointestinal stromal tumors—definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis. Virchows Arch 2001;438(1):1–12. [11] Begos D, Sandor A, Modlin I. The diagnosis and management of adult intussusception. Am J Surg 1997;173(2):88–94. [12] Eisen L, Cunningham J, Aufses A. Intussusception in adults: institutional review. J Am Coll Surg 1999;188(4):390–5. [13] DeMatteo R, Lewis JJ, Leung D, Mudan SS, Woodruff JM, Brennan MF. Two hundred gastrointestinal stromal tumors recurrence patterns and prognostic factors for survival. Ann Surg 2000;231(1):51–8.
Please cite this article as: Gelabert C, et al, Ileocolic intussusception secondary to gastrointestinal stromal tumor in a 61-year-old: a case report, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.03.037
