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肠套叠影像学检查概述

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肠套叠影像学检查概述 IntussusceptionIntussusception Ryan Chuang, Harvard Medical School, MS IVRyan Chuang, Harvard Medical School, MS IV Gillian Lieberman, MDGillian Lieberman, MD Ryan Chuang Gillian Lieberman, MD July 2002 2 IntussusceptionIntussusception: Definition: Definit...
肠套叠影像学检查概述
IntussusceptionIntussusception Ryan Chuang, Harvard Medical School, MS IVRyan Chuang, Harvard Medical School, MS IV Gillian Lieberman, MDGillian Lieberman, MD Ryan Chuang Gillian Lieberman, MD July 2002 2 IntussusceptionIntussusception: Definition: Definition Ryan Chuang Gillian Lieberman, MD • slipping of a length of intestine into an adjacent portion producing obstruction. www.intellihealth.com www.mayoclinic.com Intussusceptum Intussuscipiens 3 Types of Types of IntussusceptionIntussusception Ryan Chuang Gillian Lieberman, MD Anatomic Classification – Ileocolic – Ileoileal – Colocolic – Ileoileocolic The CIBA Collection of Medical Illustrations; Vol. 3 Digestive System, Part II, Lower Digestive Tract. Netter, Frank, MD. 4 IntussusceptionIntussusception Ryan Chuang Gillian Lieberman, MD Etiologic Classification 1) Classical “idiopathic” presentation - Mostly between ages 3 months – 3 years - Occurs more often in males than females - Theory of Hypertrophied Lymph Tissue Predisposition 2) Defined “lead point” cause - Occurs in all ages - < 10% of all cases - Generally requires surgical intervention 5 Possible Lead PointsPossible Lead Points Ryan Chuang Gillian Lieberman, MD • Meckel’s diverticulum • Intestinal polyp • Intramural hematoma • Enteric duplication • Lipoma Can occur in pts w/ lymphomas, Henoch- Schönlein purpura, Peutz-Jeghers Syndrome, etc. 6 Patient #1Patient #1 Ryan Chuang Gillian Lieberman, MD • 48 yo male w/ hx of tuberous sclerosis, mental retardation, and a seizure disorder • Chief complaint on presentation: increased seizures, fever • Incidental finding: “rigid abdomen” • Therefore, an abdominal CT was performed 7 Patient #1: CT ImagesPatient #1: CT Images Ryan Chuang Gillian Lieberman, MD Small bowel-small bowel intussusception Target Sign Courtesy of the BIDMC Radiology Department 8 Patient #1: CT ReconstructionPatient #1: CT Reconstruction Ryan Chuang Gillian Lieberman, MD Courtesy of the BIDMC Radiology Department Intussusception, Coronal View 9 Patient #2Patient #2 Ryan Chuang Gillian Lieberman, MD • 38 yo female w/ severe abdominal cramping and several episodes of bloody diarrhea presented at the Lahey ER • Given IV fluids; Tolerated BRAT diet but 24 hours later, presented to PCP w/ RUQ & peri-umbilical pain, relieved by eating, radiating to back. • No further diarrhea, no BRBPR, no melena 10 Patient #2Patient #2 Ryan Chuang Gillian Lieberman, MD • On PE, pt had mild RUQ tenderness • No guarding, no rebound, no masses felt • Bowel sounds are NL • On U/S, liver, spleen, and gallbladder all appeared NL • Stool Cultures Pending • Family Hx negative for IBD or Colitis 11 Patient #2Patient #2 Ryan Chuang Gillian Lieberman, MD • Pt referred to the BIDMC • More history elicited… • No fevers or chills • No nausea or vomiting • Positive flatus and bowel movements • Had 2x similar episodes within past month; Both resolved spontaneously. Most recent one associated with 3X of bloody stools 12 Patient #2Patient #2 Ryan Chuang Gillian Lieberman, MD • Pt takes no medications • Pt had no significant PMH • Pt had no history of surgeries • Colonoscopy done 2 yrs earlier was NL • Vital signs stable; Labs unremarkable TIME TO IMAGE!!! TIME TO IMAGE!!! ☺☺ Abdominal CT and BE were performedAbdominal CT and BE were performed 13 Patient #2: CT ScanPatient #2: CT Scan Ryan Chuang Gillian Lieberman, MD Mid-Transverse Colon Intussusception w/ associated mesentary stranding. Lead point: 3.5x4.7 cm fatty mass representing an intraluminal lipoma. Lipoma Courtesy of the BIDMC Radiology Department 14 Patient #2: Barium EnemaPatient #2: Barium Enema Ryan Chuang Gillian Lieberman, MD Barium enema performed next day showed contrast freely through the sigmoid and descending colon to the level of the mid-transverse colon and a large, rounded, intraluminal filling defect w/in the mid-transverse colon. Courtesy of the BIDMC Radiology Department 15 Patient #2: Barium EnemaPatient #2: Barium Enema Ryan Chuang Gillian Lieberman, MD Courtesy of the BIDMC Radiology Department Colocolic Intussusception 16 Patient #2: Barium EnemaPatient #2: Barium Enema Ryan Chuang Gillian Lieberman, MD • Barium enema has often been used to diagnosis and treat intussusception • Standard method of reduction: rule of 3s - barium placed 3 feet above pt - let hang for 3 minutes - 3 tries before going to surgery • If suspect bowel perforation, use H2 0- soluble contrast 17 Patient #2Patient #2 Ryan Chuang Gillian Lieberman, MD • For this pt, surgery treatment necessary • A right hemicolectomy w/ the lipoma removed was performed a day after the barium enema • Pt tolerated surgery well • Pt went home POD #3 in stable condition with Percocet for pain 18 Patient #3Patient #3 Ryan Chuang Gillian Lieberman, MD • 14 yo boy w/ a 6 month hx of intermittent abdominal pain. • Most recent episode of pain started one wk before presentation and associated w/ nausea and 2x emesis • No fever, diarrhea, hematemesis, hematochezia nor melena 19 Patient #3Patient #3 Ryan Chuang Gillian Lieberman, MD • On PE, abdomen was diffusely tender • No masses palpable • No blood in stool • Prior CT at outside facility reportedly NL • Initial plain films of the abdomen taken… 20 Patient #3: Plain FilmPatient #3: Plain Film Ryan Chuang Gillian Lieberman, MD Courtesy of the Children’s Hospital, Boston Plain film: Some small bowel distention w/ multiple air-fluid levels in the small bowel and paucity of gas in the large bowel 21 Patient #3: Abdominal CTPatient #3: Abdominal CT Ryan Chuang Gillian Lieberman, MD • Pt failed to improve, so a repeat abdominal CT was performed Ileoileal Intussusception Courtesy of the Children’s Hospital, Boston 22 Patient #3Patient #3 Ryan Chuang Gillian Lieberman, MD • CT scan revealed an ileoileal intussusception • Pt went to the operating room • Findings in the OR: Straw-colored ascites fluid, an ileoileal intussusception, and an inverted Meckel’s diverticulum • The intussusception was manually reduced • Meckel’s was resected, incidental appy performed, and pt did well post-op. 23 Patient #4Patient #4 Ryan Chuang Gillian Lieberman, MD • 5 yo child presents with one week history of severe, intermittent, cramping abdominal pain, nausea and vomiting and 1x episode of blood in stool. • Pt thought to have constipation – given 1x Fleet Enema for Children • Pain felt worse, pt came to the Boston Children’s Hospital ER 24 Patient #4Patient #4 Ryan Chuang Gillian Lieberman, MD • Except for age, this is a more classical presentation of intussusception • Common symptoms include intermittent, severe, crampy abdominal pain, vomiting and bloody stools • Classic triad of abdominal pain, currant- jelly stools, and a sausage-shaped abdominal mass in R side of abdomen 25 Patient #4: UltrasoundPatient #4: Ultrasound Ryan Chuang Gillian Lieberman, MD Pt had U/S exam in ER: Courtesy of the Children’s Hospital, Boston RUQ Transverse View “Bull’s eye” / “Coiled spring” sign of Intussusception 26 Patient #4: UltrasoundPatient #4: Ultrasound Ryan Chuang Gillian Lieberman, MD • U/S sensitivity and specificity for intussusception approaches 100% • Classic U/S image: “bull’s eye” or “coiled spring” lesions representing layers of intestine within intestine. • Lack of perfusion in intussusceptum detected w/ color duplex imaging may indicate development of ischemia 27 Patient #4: Air EnemaPatient #4: Air Enema Ryan Chuang Gillian Lieberman, MD • With positive dx of Intussusception on U/S, the pt proceeded to an air enema • Technique introduced in N. America by Chinese physicians in 1970s • Perforation rate of <1% • Maximum P from air enema – 120 mmHg • 75-90% success rate 28 Patient #4: Air EnemaPatient #4: Air Enema Ryan Chuang Gillian Lieberman, MD Courtesy of the Children’s Hospital, Boston Pt in prone position on exam table L R Crescent Sign 29 Patient #4: Air EnemaEnema Ryan Chuang Gillian Lieberman, MD • Crescent Sign – leading edge of the intussusceptum in the intussuscepiens • Place child in prone position for air enema, hold down tightly, can feel a characteristic “pop” upon reduction • If not working in prone position, can flip child over to supine and try again… 30 Patient #4: Air EnemaPatient #4: Air Enema Ryan Chuang Gillian Lieberman, MD Courtesy of the Children’s Hospital, Boston Pt in Supine Position on Exam Table L LRR 31 Patient #4Patient #4 Ryan Chuang Gillian Lieberman, MD • Ileocecal intusussception successfully reduced in supine position!!! ☺ • Recurrence after successful nonoperative reduction is approximately 10% • Recurrences should be handled as if it were an original episode • Recurrences after surgery are <1% 32 IntussusceptionIntussusception: Overview: Overview Ryan Chuang Gillian Lieberman, MD • Common cause of intestinal obstruction in young children (typically 3 mo – 3 yrs) • Affects boy greater than girls • Most often seen in spring and fall • Symptoms include intense abdominal pain, vomiting, fever, irritability, lethargy, and currant jelly stool. 33 IntussusceptionIntussusception: Overview: Overview Ryan Chuang Gillian Lieberman, MD Role of Radiology: Diagnosis and CURE! • Abdominal X-ray – May show obstruction • Abdominal CT – Better at showing lesion • Ultrasound – Very sensitive AND specific • Barium Enema – Diagnostic and Curative! • Air Enema – Also Diagnostic and Curative! 34 ReferencesReferences Ryan Chuang Gillian Lieberman, MD Lecture:Lecture: “Intussusception.” Children’s Department Radiology Rounds, Dr. Carlo Buonomo. July 18, 2002 Web Sites:Web Sites: www.uptodate.com www.mayoclinic.com www.intellihealth.com Literature:Literature: The CIBA Collection of Medical Illustrations. Vol. 3 Digestive System, Part II Lower Digestive Tract. P. 134 “Intussusception.” Netter, Frank, MD. The Radiologic Clinics of North America: Imaging the Acute Abdomen (Sept. ’94), Pediatric Gastrointestinal Radiology (July ’96), and the Imaging of the Acute Pediatric Abdomen (July ’97). W.B. Saunders Co. 35 AcknowledgementsAcknowledgements SPECIAL THANKS TO:SPECIAL THANKS TO: The BIDMC Radiology DepartmentThe BIDMC Radiology Department Gillian Lieberman, MD; Course Director Pamela Lepkowski, Course Assistant Larry Barbaras and Cara Lyn D’amour, Webmasters Residents Daniel Saurborn, MD; Michelle Swire, MD Residents Matthew Spencer, MD; Michael Goldfinger, MD Children’s Hospital, Boston, Radiology Dept.Children’s Hospital, Boston, Radiology Dept. Dr. Carlo Buonomo, MD Dr. Michael Callahan, MD And Christian Dancz, HMS III Ryan Chuang Gillian Lieberman, MD THE END!!! THE END!!! ☺☺ Intussusception Intussusception: Definition Types of Intussusception Intussusception Possible Lead Points Patient #1 Patient #1: CT Images Patient #1: CT Reconstruction Patient #2 Patient #2 Patient #2 Patient #2 Patient #2: CT Scan Patient #2: Barium Enema Patient #2: Barium Enema Patient #2: Barium Enema Patient #2 Patient #3 Patient #3 Patient #3: Plain Film Patient #3: Abdominal CT Patient #3 Patient #4 Patient #4 Patient #4: Ultrasound Patient #4: Ultrasound Patient #4: Air Enema Patient #4: Air Enema Patient #4: Air Enema Patient #4: Air Enema Patient #4 Intussusception: Overview Intussusception: Overview Slide Number 34 Acknowledgements
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