Case Report
 

By Dr. C Surendranath Singh , Prof. M.l. Prakash
Corresponding Author Dr. C Surendranath Singh
Unit of Radiodiagnosis, Faculty of Medicine, AIMST University, Jalan Semeling-Bedong - Malaysia 08100
Submitting Author Dr. C Surendranath Singh
Other Authors Prof. M.l. Prakash
Department of Imaging Sciences, Mahatma Gandhi Medical College & Research Centre, Puducherry, - India

RADIOLOGY

Intussusception, Adult Intussusception, Ileocecal, Imaging, Plain X-Ray, Barium Enema, USG, CT

Singh C, Prakash M. Adult Intussception : A Case Report. WebmedCentral RADIOLOGY 2011;2(7):WMC002052
doi: 10.9754/journal.wmc.2011.002052
Yes
Submitted on: 28 Jul 2011 08:12:12 AM GMT
Published on: 28 Jul 2011 06:49:09 PM GMT

Abstract


Intussusception in adults is rare. This is a case of ileo-colic intussusception in a 65 year old lady with characteristic radiological signs on plain x-ray, Ultrasonogram, barium enema and contrast enhanced CT. The lead point could be identified and was suspected to be a MALTOMA.

Introduction


Intussusception in adults is distinctly rare and makes the diagnosis challenging. A high degree of clinical suspicion, especially in the emergency setting, is required. The identification of a “lead point” which may be a primary or a secondary malignancy has a bearing on the subsequent management. This is an illustrative case of adult intussusception that showed classical features on several imaging modalities (viz., Plain x- ray abdomen, ultra sonogram, barium enema, and contrast C T examination).

Case Report


A 65 year old female was admitted with a history of intermittent upper abdominal pain for 6-8 months with occasional vomiting, and passage of black coloured stools that had exacerbated in the week prior to admission. She was being treated with omeprazole and antacids for herniation at the gastro-oesophageal junction and antral gastritis following an upper gastrointestinal endoscopy.
On examination, she was pale and there was tenderness in the epigastrium. With a clinical suspicion of intermittent intestinal obstruction she was further investigated. Plain x-ray of the abdomen showed the presence of a crescent shaped soft tissue mass (Meniscus sign) in the line of the colon (Fig 1). Ultrasonogram of the abdomen showed a mass with concentric rings -Target sign with cental hyperdense lesion (lead point) on transverse section. The longitudinal section of the same area revealed hypoechoic areas separated by linear hyperechoic strands (Hay-fork sign) (Fig 2 &3) 4. Subsequent Doppler interrogation showed normal flow in the mesenteric vessels(Fig 4). Barium contrast examination of the colon revealed coiled spring appearance near right hepatic flexure (Fig 5). Following this a Contrast C T examination showed a bowel-in-bowel appearance with intact blood flow in the mesenteric vessels and presence of lead point (Fig 6a & b).

Discussion


Based on these observations, a diagnosis of ileo-caecal intussusception with a lead point was made and the patient was advised surgery. The entire lesion was resected followed by end to end ileo-colic anastomosis.
Gross examination of the resected specimen confirmed the presence of the lead point (Fig 7) which was provisionally suspected to be a MALTOMA histologically.Intussusception in adults is reported to be rare and accounts for 5% of all intussusceptions and has been reported to be as infrequent as 0.003 – 0.02% of all adult hospital admissions1,2. In this case the patient presented with reflux symptoms almost identical to an earlier report3 Imaging is an important modality for the diagnosis of adult intussusceptions. In general radiological diagnosis of intussusceptions has a high sensitivity and specificity. Plain X-ray of the abdomen with the characteristic meniscus sign has an accuracy of 40%-90%4-7. In barium enema the coiled-spring sign is diagnostic7. Currently ultrosonography has been found to be extremely useful with a sensitivity of 98%-100% 2. Ultrasonography has the added advantage of being non-invasive and economical. However this is dependent on the skills of the operator.The “multi-concentric sign”8, “hay fork sign” 4 and the “target sign”9 are suggestive bowel within bowel which is characteristic of intussusceptions. The “target sign” (bowel –in bowel appearance) which is detectable on ultrasonography is also identifiable on CT 10. A Multi detector computed tomogram [MDCT] with contrast enhancement is a useful tool for diagnosis particularly in the identification of a lead point11.
A lead point is fairly frequent in adults and its detection is extremely important since a malignant lesion is reported 28%-80% of cases 1, 11. This case has been presented in view of the characteristic radiological signs observed on different available radiological modalities. This is of educative value and reinforces the utility of imaging in diagnosis of intusussception.

References


1. Azar T and Berger DL. Adult intussusception. Annals  Surg 1997; 226: 134-138.
2. Kim MC, Strouse PJ, Peh WC. . Clinics in Diagnostic Imaging. Singapore Med J. 2002;43: 645-648.
3. Yalarmathi S and Smith RC. Adult intussusception: case reports and review of literature .Postgrad Med J 2005;81:174-177.
4. Alessi V, Salerno G. The "hay-fork" sign in the ultrasonographic diagnosis of intussusception. Gastrointest Radiol. 1985; 10:177–179.
5. Sargent MA, Babyn P, Alton DJ. Plain abdominal radiography in suspected intussusception: a reassessment. Pediatr Radiol 1994; 24:17-20.
6. Elkof O, Martelius H. Reliability of the abdominal plain film diagnosis in pediatric patients with suspected intussusception. Pediatr Radiol 1980; 9:199-206.
7. Meradji M, Hussain SM, Robben SGF, Hop WCJ. Plain film diagnosis in intussusception. Br J Radiol 1994; 67:147-149.
8. Holt S, Samuel E. Multiple concentric ring sign in the ultrasonographic diagnosis of intussusception. Gastrointest Radiol. 1978; 3:307–309.
9. Weissberg DL, Scheible W, Leopold GR. Ultrasonographic appearance of adult intussusception. Radiology. 1977;124:791–792.
10. Beattie GC, Peters RT, Guy S, Mendelson RM. Computed tomography in the assessment of suspected large bowel obstruction. ANZ J Surg. 2007;77: 160–165.
11. Tresoldi S, Kim YH, Blake MA, Harisinghani MG, Hahn PF, Baker SP et al. Adult intestinal intussusception: can abdominal MDCT distinguish an intussusception caused by a lead point? Abdom Imaging 2008; 33: 582–588.

Source(s) of Funding


none

Competing Interests


none

Disclaimer


This article has been downloaded from WebmedCentral. With our unique author driven post publication peer review, contents posted on this web portal do not undergo any prepublication peer or editorial review. It is completely the responsibility of the authors to ensure not only scientific and ethical standards of the manuscript but also its grammatical accuracy. Authors must ensure that they obtain all the necessary permissions before submitting any information that requires obtaining a consent or approval from a third party. Authors should also ensure not to submit any information which they do not have the copyright of or of which they have transferred the copyrights to a third party.
Contents on WebmedCentral are purely for biomedical researchers and scientists. They are not meant to cater to the needs of an individual patient. The web portal or any content(s) therein is neither designed to support, nor replace, the relationship that exists between a patient/site visitor and his/her physician. Your use of the WebmedCentral site and its contents is entirely at your own risk. We do not take any responsibility for any harm that you may suffer or inflict on a third person by following the contents of this website.

Reviews
4 reviews posted so far

Imaging in intussception
Posted by Dr. Shyamsunder R Koteyar on 07 Jan 2012 01:29:30 PM GMT

Adult Intussception
Posted by Dr. Thomas F Heston on 22 Sep 2011 04:19:56 PM GMT

ADULT INTUSSCEPTION ; A CASE REPORT
Posted by Dr. DURGA PRASAD K BHAMIDIPATY on 07 Aug 2011 07:18:45 AM GMT

adult intussception
Posted by Prof. Syed A Gilani on 31 Jul 2011 05:15:59 AM GMT

Comments
0 comments posted so far

Please use this functionality to flag objectionable, inappropriate, inaccurate, and offensive content to WebmedCentral Team and the authors.

 

Author Comments
0 comments posted so far

 

WebmedCentral Article: Adult Intussception : A Case Report

What is article Popularity?

Article popularity is calculated by considering the scores: age of the article
Popularity = (P - 1) / (T + 2)^1.5
Where
P : points is the sum of individual scores, which includes article Views, Downloads, Reviews, Comments and their weightage

Scores   Weightage
Views Points X 1
Download Points X 2
Comment Points X 5
Review Points X 10
Points= sum(Views Points + Download Points + Comment Points + Review Points)
T : time since submission in hours.
P is subtracted by 1 to negate submitter's vote.
Age factor is (time since submission in hours plus two) to the power of 1.5.factor.

How Article Quality Works?

For each article Authors/Readers, Reviewers and WMC Editors can review/rate the articles. These ratings are used to determine Feedback Scores.

In most cases, article receive ratings in the range of 0 to 10. We calculate average of all the ratings and consider it as article quality.

Quality=Average(Authors/Readers Ratings + Reviewers Ratings + WMC Editor Ratings)