Yet another case of abdominal pain?

May 08, 2018 By: Matteo Revelli

Figure 1 | Anteroposterior plain radiograph of the abdomen, acquired in standing position, showing air distention of several small bowel loops, associated with the presence of levels suggesting bowel obstruction.

Yet another case of abdominal pain? 

A 41-year-old man with a recent history of weight loss, reduced appetite and nausea... 

A 41-year-old man with a recent history of weight loss, reduced appetite and nausea presents with acute abdominal pain.

On physical examination he has abdominal distension without tenderness but pain during deep palpation, Blumberg’s sign is negative and bowel sounds are sparse. The initial radiography findings are shown in figure 1 and his blood test results are shown in table 1. 

Table 1 | Blood test results at presentation. Click on the picture to enlarge the table.

 

 

 

 

At this stage, would you choose to give laxatives and discharge the patient, urgently perform a CT scan or endoscopy, or give a prokinetic, antibiotics, laxatives and monitor the patient every 6h? The correct decision here is to perform a CT scan, which is what the case patient underwent—the findings are shown in figure 2. 

Figure 2 | Abdominal contrast-enhanced CT scan with coronal and sagittal reconstructions; images were acquired at portal venous time (about 70 seconds after injection of iodinated contrast medium).

 

 

Case Question 1

WHAT IS YOUR CLINICAL DIAGNOSIS AT THIS POINT?

a) Intestinal ischaemia
b) Crohn’s Disease
c) Intussusception
d) Megacolon

Answer to case question 1, discussion and case question 2

Answer to Case Question 1 

Correct answer: C.

 

Discussion

The yellow arrows on figure 3 indicate the presence of small bowel intussusceptions involving different segments of ileal loop in the case patient.

 

Figure 3 | Small bowel intussusceptions involving different segments of ileal loops are highlighted by the yellow arrows on the multiplanar abdominal contrast-enhanced CT images shown in figure 2. 

Intussusception is a serious condition in which part of the intestine slides into an adjacent part of the intestine. This ‘telescoping’ often blocks food or fluid from passing through the intestine. Intussusception also cuts off the blood supply to the part of the intestine that’s affected, which can lead to a tear in the bowel (perforation), infection and death of bowel tissue.1

Intussusception is the most frequent cause of bowel obstruction in paediatric patients;2however, it may occur in adults as the result of an underlying medical condition, such as a tumour, which may act as lead point, dragging part of the bowel into the neighbouring segment.3

There are several medical conditions/situations known to contribute to intussusception in adults:

  • Congenital abnormalities (e.g. Meckel diverticulum, ectopic pancreas, duplication cyst)
  • A polyp or tumour
  • Scar-like tissue (adhesions) in the intestine 
  • Weight-loss surgery (gastric bypass) or other surgery on the gastrointestinal tract
  • Gastrointestinal inflammation caused by disease (e.g. Crohn's disease)

When intussusception occurs in adults, the most frequent symptom is abdominal pain that comes and goes. Nausea and vomiting may also occur. People sometimes have symptoms for weeks before seeking medical attention. A repeat CT scan was performed, and the findings are shown in figure 4.

 

Figure 4 | Second-look of abdominal contrast-enhanced CT scan with coronal and sagittal reconstructions; images were acquired at portal venous time (about 70 seconds after injection of iodinated contrast medium).

 

Case Question 2     

WHAT IS YOUR CLINICAL DIAGNOSIS AT THIS POINT?

a) Congenital abnormality

b) Intestinal lymphoma

c) Polyp syndrome (e.g. FAP, Peutz-Jeghers syndrome, etc.)

d) Metastases

Answer to case question 2 and discussion

Answer to case question 2

Correct answer: D.

 

Discussion

Congenital abnormalities are more likely in young patients and a single area of the bowel is usually involved. 17–30% of small bowel tumours are lymphomas, but they are solitary lesions or involve a single portion of the small bowel (5–20 cm). Furthermore, on imaging they are observed to have the same thickness as the bowel wall. A polyp syndrome is unlikely in this case because FAP involves the colon, while Peutz-Jeghers syndrome involves the small bowel, but melanosis is usually present as well. 

Small intestinal metastases are rare and originate mostly from kidney carcinoma or melanoma, but they were suspected to be the cause of the intussusception in the case patient because metastases had been noticed in the liver (figure 5).

 

Figure 5 | A more accurate evaluation of the images in figure 4 allows the identification of multiple enhancing nodules distributed along the walls of the small bowel, as well of several enlarged lymph nodes within the mesenteric fat (a,b,c). Parenchymal evaluation also depicts a subglissonian liver nodule, characterized by slight hypodensity (d,e). Both kidneys show normal morphology and absence of nodular lesions (f).

 

Biopsy samples were taken from the hepatic nodules and the duodenum was resected, and the findings confirmed metastases of an epithelioid-cell-type melanoma to the enteric wall, liver and peritoneum. The case patient subsequently developed neurological manifestations (figure 6). 

 

 

Figure 6 | Unenhanced head CT showing the presence of multiple nodules, involving both cerebral and cerebellar parenchyma, consistent with cerebral metastases. 

 

Metastatic melanoma affects the small bowel more often than the colon.Unfortunately, the disease has a late clinical onset and diagnosis is often made only when complications, such as bleeding, obstruction or perforation, occur.  However, there are only few reports of small bowel intussusception caused by melanoma.CT is important for diagnosis and staging, followed by histology.6,7 Surgery is often required as is palliative treatment to manage complications (+/- adjuvant chemo/radiotherapy).8

About the author

Matteo Revelli works as consultant at Reggio Emilia AUSL - IRCCS Department of Diagnostic Imaging and Laboratory Medicine in Reggio Emilia, Italy. He graduated in medicine in 2008 and undertook his radiology postgraduate education in 2014 at Genoa University. His main clinical and research fields of interest include gastroenterological, cardiac and urogenital radiology. He is author or coauthor of more than 80 papers, including scientific articles indexed on Pubmed, multimedia publications, posters and oral presentations presented at national and international conferences. 

 

Comments

, May 13, 2018 14:23
Intussusception
, May 10, 2018 11:56
Intussusception
, May 09, 2018 22:52
Intussusception
Stavros Dimitriadis, May 09, 2018 16:34
C. Intussusception
Luca covotta, May 08, 2018 16:21
Intussusception

More Education News