成人肠套叠的影像学诊断

Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD Adult Adult IntussusceptionIntussusception Sherry Sherry FarzanFarzan--KashaniKashani, HMS III, HMS III Gillian Lieberman, MDGillian Lieberman, MD Core Radiology RotationCore Radiology Rotation August 2003August 2003 Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 22 What is What is IntussusceptionIntussusception??  Telescoping of proximal Telescoping of proximal segment segment ((intussusceptumintussusceptum)) of GI of GI tract into an adjacent and tract into an adjacent and distal one distal one ((intussuscepiensintussuscepiens))  Commonly seen in Commonly seen in pediatric population as pediatric population as ileocolicileocolic w/o identifiable w/o identifiable lesion (95%)lesion (95%)  Rare cause of obstruction Rare cause of obstruction in adults w/ identifiable in adults w/ identifiable lesion (5%)lesion (5%) www.pedisurg.comwww.pedisurg.com intussusceptum intussuscepiens Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 33 What Happens Next?What Happens Next?  As As intussusceptumintussusceptum telescopes into telescopes into intussuscepiensintussuscepiens, , mesentery containing mesentery containing vascular components is vascular components is trapped between the two trapped between the two layers of bowellayers of bowel  Vascular compression Vascular compression  bowel edema bowel edema  further further vascular compression vascular compression  ischemic necrosis ischemic necrosis  peritonitis, aberrant airperitonitis, aberrant air Courtesy of Dr. Wendy Durgin Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 44 Gross PathologyGross Pathology Feldman: Sleisenger & Fordtran's Gastrointestinal and Liver Disease, 7th ed p 2119-2120. On the left, the intussusceptum has become ischemic. On the right, opening the outer layer reveals the telescoping of the intussusceptum. Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 55 Patient R.S.Patient R.S.  CC: 25yo male with bilateral upper quadrant CC: 25yo male with bilateral upper quadrant ““needleneedle--likelike”” pain; presented at clinicpain; presented at clinic  PMH:PMH:  s/ps/p orthotopicorthotopic liver transplant one year ago for liver transplant one year ago for fulminantfulminant liver failureliver failure  RouxRoux--enen--Y Y hepaticojejunostomyhepaticojejunostomy  Hepatic artery Hepatic artery stentingstenting five five months agomonths ago  Admitted for GI series workAdmitted for GI series work--upup www.danaise.com Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 66 Patient R.S.Patient R.S.  PE @ BIDMCPE @ BIDMC  No acute distressNo acute distress  Abdomen soft and Abdomen soft and nondistendednondistended  Bilateral upper quadrant tenderness without Bilateral upper quadrant tenderness without rebound or guardingrebound or guarding  Otherwise unremarkableOtherwise unremarkable Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 77 Differential DiagnosisDifferential Diagnosis  Organ Rejection/ThrombosisOrgan Rejection/Thrombosis  AdhesionsAdhesions  Bowel ObstructionBowel Obstruction  IntussusceptionIntussusception  Abdominal HerniaAbdominal Hernia  Abdominal MassAbdominal Mass  GI BleedGI Bleed  CholecystitisCholecystitis  ConstipationConstipation  UlcerUlcer Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 88 CTA of LiverCTA of Liver Lead Point Mesenteric vessels Dilated proximal jejunal loop with debris BIDMC Radiology Department Liver Kidneys Aorta Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 99 CTA of LiverCTA of Liver mesenteric vessels BIDMC Radiology Department Target Lesion intussuscepiens intussusceptum Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 1010 CTA of LiverCTA of Liver BIDMC Radiology Department intussusceptum intussuscepiens mesenteric vessels Sausage lesion Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 1111 Oblique ReconstructionOblique Reconstruction intussusceptiens intussusceptumEnhancing mesenteric vessels BIDMC Radiology Department Surgical staples Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 1212 Delayed ImagingDelayed Imaging BIDMC Radiology Department Intussusception has resolved Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 1313 Barium Swallow with Small Bowel Barium Swallow with Small Bowel Follow ThroughFollow Through Filling defect consistent with intussucepted small bowel BIDMC Radiology Department Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 1414 Intermittent PropulsionIntermittent Propulsion BIDMC Radiology Department BIDMC Radiology Department In real time, the intussusceptum moved in and out of the intussuscepiens. Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 1515 Diagnosis for Patient R.S.Diagnosis for Patient R.S.  Chronic transient Chronic transient intussusceptionintussusception  Surgical sutures within Surgical sutures within intussusceptionintussusception suggest involvement as lead point suggest involvement as lead point Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 1616 IntussusceptionIntussusception Adults vs. ChildrenAdults vs. Children  1% of all adult bowel 1% of all adult bowel obstxnobstxn (only 53 cases @ (only 53 cases @ MGH btw 1964MGH btw 1964--19931993  5% of all 5% of all intussusceptionintussusception  Demonstrable etiology in Demonstrable etiology in 7070--90% 90%  Acute, intermittent, or Acute, intermittent, or chronic (chronic (““acute abdomenacute abdomen”” is rareis rare  Enteric, Enteric, ileocolicileocolic, , ileocecalileocecal, colonic, colonic  Surgical resection Surgical resection  22ndnd most common most common abdominal emergency in abdominal emergency in childrenchildren  95% of all 95% of all intussusceptionintussusception  Usually no demonstrable Usually no demonstrable etiologyetiology  Acute presentationAcute presentation  IleocolicIleocolic  NonNon--operative reductionoperative reduction Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 1717 Signs & Symptoms in AdultsSigns & Symptoms in Adults  Intermittent/chronic Intermittent/chronic abdominal pain (70abdominal pain (70--90%)90%)  VomittingVomitting/Nausea (80%)/Nausea (80%)  Red blood per rectum (30%)Red blood per rectum (30%)  Abdominal distension/ Abdominal distension/ shiftingshifting mass (10mass (10--40%)40%)  Weight loss (10%)Weight loss (10%)  Fever (10%)Fever (10%)  Chronic constipation or diarrhea (<10%)Chronic constipation or diarrhea (<10%)  Acute (24hr), intermittent, and chronic (5yr)Acute (24hr), intermittent, and chronic (5yr) Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 1818 Etiology in AdultsEtiology in Adults  NeoplasticNeoplastic ProcessProcess  NonNon--NeoplasticNeoplastic ProcessProcess  Idiopathic ProcessIdiopathic Process Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 1919 NeoplasticNeoplastic IntussusceptionIntussusception  BenignBenign  LipomaLipoma  AdenomatousAdenomatous polyppolyp  MeckelMeckel’’ss DiverticulumDiverticulum  HamartomatousHamartomatous polyppolyp  HemangiomaHemangioma  LeiomyomaLeiomyoma  NeurofibromaNeurofibroma  Malignant Malignant  Primary Primary –– adenoCAadenoCA, , leiomyosarcomaleiomyosarcoma, , carcinoidcarcinoid, lymphoma, , lymphoma, KaposiKaposi’’ss  Metastatic Metastatic –– melanoma, lymphoma, sarcomamelanoma, lymphoma, sarcoma Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 2020 NonNon--NeoplasticNeoplastic & Idiopathic & Idiopathic IntussusceptionIntussusception  NonNon--NeoplasticNeoplastic  PostPost--Op: Adhesions, suture lines, edema, Op: Adhesions, suture lines, edema, dysmotilitydysmotility  Inflammatory lesions: Inflammatory lesions: CrohnCrohn’’ss, lymphoid hyperplasia , lymphoid hyperplasia (AIDS)(AIDS)  Disordered motilityDisordered motility  May be permanent or transientMay be permanent or transient  IdiopathicIdiopathic –– no etiology foundno etiology found Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 2121 PathophysiologyPathophysiology  Lead point seen in >90% of casesLead point seen in >90% of cases  Primarily in small bowelPrimarily in small bowel  JJ--J, IJ, I--I, II, I--Co, ICo, I--CeCe, S, S--R, R, CeCe--CoCo  PeristalsisPeristalsis  Peristalsis and ingested food push Peristalsis and ingested food push intussusceptumintussusceptum into relaxed and distal into relaxed and distal intussuscipiensintussuscipiens  Tends to occur at Tends to occur at jnxjnx of free bowel and of free bowel and retroperitoneal/fixed segments (e.g. retroperitoneal/fixed segments (e.g. ileoileo--cecalcecal)) Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 2222 PostPost--Surgical Surgical IntussusceptionIntussusception  50% of benign intussusceptions50% of benign intussusceptions  Complication of RouxComplication of Roux--enen--Y limbsY limbs  Retrograde Retrograde intussusceptionintussusception (anti(anti--peristaltic) peristaltic) through Rouxthrough Roux--enen--Y Y anastomosisanastomosis  RouxRoux--enen--Y stasis syndromeY stasis syndrome  Lead point may be suture line or adhesionLead point may be suture line or adhesion  Reduction without resection is reasonable Reduction without resection is reasonable if bowel is viableif bowel is viable Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 2323 Transient Transient IntussusceptionIntussusception  Completely resolved on Completely resolved on f/uf/u examsexams  Accounts for many of nonAccounts for many of non--neoplasticneoplastic cases cases  Commonly seen in Celiac Disease (20%)Commonly seen in Celiac Disease (20%)  Loss of normal tone in small bowel due to toxic Loss of normal tone in small bowel due to toxic effects of gluteneffects of gluten  Flaccid loops are more susceptible to Flaccid loops are more susceptible to intussusceptionintussusception  Diarrheal diseases w/ abnormal bowel motilityDiarrheal diseases w/ abnormal bowel motility  Increasingly seen because of CT scansIncreasingly seen because of CT scans Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 2424 Management of Transient Management of Transient IntussusceptionIntussusception  Younger pts w/ smaller, shorter intussusceptionsYounger pts w/ smaller, shorter intussusceptions  length of <3.5cm on CT was independently predictive length of <3.5cm on CT was independently predictive of transienceof transience  Likely nonLikely non--neoplasticneoplastic  These pts treated conservatively and did not have These pts treated conservatively and did not have recurrence at recurrence at f/uf/u > 100days> 100days  Questionable clinical significance; possibly Questionable clinical significance; possibly physiologicalphysiological Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 2525 Diagnostic ProceduresDiagnostic Procedures  Plain Abdominal FilmsPlain Abdominal Films  Upper GI Series Upper GI Series  Barium EnemaBarium Enema  UltrasoundUltrasound  CTCT Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 2626 Plain Abdominal FilmsPlain Abdominal Films  May see airMay see air--fluid levels in fluid levels in dilated bowel loops if dilated bowel loops if obstruction is sufficientobstruction is sufficient  Meniscus sign (leading Meniscus sign (leading edge of edge of intussusceptumintussusceptum))  0% accuracy in adults in 0% accuracy in adults in one studyone study  Used to R/O free air prior Used to R/O free air prior to enema reductionto enema reduction Daneman et al. Pediatr Radiol 2003; 33: 79-85 Soft tissue abdominal mass Meniscus sign Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 2727 Upper GI Series and Small Bowel Upper GI Series and Small Bowel Follow ThroughFollow Through  Bowel within bowelBowel within bowel  Filling defect Filling defect indicating obstructionindicating obstruction  Accuracy of 21% in Accuracy of 21% in adults in one studyadults in one study  Possibly therapeutic Possibly therapeutic when when invaginationinvagination compressed compressed BIDMC Radiology Dept Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 2828 Barium EnemaBarium Enema  Cup shaped filling Cup shaped filling defect defect  Coil spring Coil spring  Accuracy of 54% in Accuracy of 54% in adults in one studyadults in one study  Contraindicated if Contraindicated if suspected bowel suspected bowel perforation or perforation or ischemiaischemia Coil Spring appearance Cup-Shaped Filling Defect Matsuba Y et al. J Gastroenterol. 2003;38(2):181-5 Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 2929 Air EnemaAir Enema intussusceptum www.uptodate.com Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 3030 UltrasonographyUltrasonography  Modality of choice in Modality of choice in pediatricspediatrics  Transverse view Transverse view –– target/donut signtarget/donut sign  Longitudinal view Longitudinal view –– pseudokidneypseudokidney/ sandwich / sandwich signsign  Limited by Limited by  presence of air in bowel presence of air in bowel  poor transmissionpoor transmission  Operator dependentOperator dependent Grainger & Allison's Diagnostic RadiologyA Textbook of Medical Imaging, 4th Ed., p1214-1216. Daneman et al. Pediatr Radiol 2003; 33: 79-85 Transverse view Longitudinal view Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 3131 CTCT  Early Early –– target target lzlz or oblong or oblong sausage shaped masssausage shaped mass  Later Later –– layering effectlayering effect  Finally Finally –– amorphous massamorphous mass  Presence of these signs is Presence of these signs is pathognomicpathognomic  +/+/-- dilation and dilation and obstxnobstxn  Most accurate Most accurate –– 78% 78% DxDx in adultsin adults  Can identify other Can identify other pathologypathology Non-Contrast CT, Transverse view Oral Contrast CT, Longitudinal view Ko et al. World J. World J. SurgSurg 2002; 26: 4382002; 26: 438––443443 Haas et al. Haas et al. Am J Am J SurgSurg 2003; 186(1): 752003; 186(1): 75--7676 Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 3232 Treatment in AdultsTreatment in Adults  Surgical ResectionSurgical Resection  Caused by neoplasm in up to 50% of casesCaused by neoplasm in up to 50% of cases  Colon Colon  en bloc en bloc resxnresxn b/cb/c hi likelihood of neoplasmhi likelihood of neoplasm  Small Bowel Small Bowel  initial initial redxnredxn then then resxnresxn if not if not neoplasticneoplastic or or infarctedinfarcted  Selective Selective adhesionolysisadhesionolysis, , diverticuletomydiverticuletomy, , polypectomypolypectomy w/o w/o resxnresxn is alternative in small bowel is alternative in small bowel casescases  With surgery, there is a low incidence of recurrenceWith surgery, there is a low incidence of recurrence Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 3333 Treatment in AdultsTreatment in Adults  Reduction via colonoscopy, Reduction via colonoscopy, insufflationinsufflation  Conservative Conservative TxTx reserved for those lesions known to reserved for those lesions known to be benign (e.g. be benign (e.g. lipomalipoma))  W/o surgery, hi risk of recurrenceW/o surgery, hi risk of recurrence  Transient Transient intussusceptionintussusception resolves on its ownresolves on its own  May not need therapeuticsMay not need therapeutics  Chronic transient Chronic transient intussusceptionintussusception –– Patient R.S.Patient R.S. Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 3434 Back to our Patient R.S.Back to our Patient R.S.  Patient remained in hospital for five daysPatient remained in hospital for five days  Sent home because in stable conditionSent home because in stable condition  Decided to have surgical procedure as Decided to have surgical procedure as outpatient to correct chronic and outpatient to correct chronic and symptomatic symptomatic intussusceptionintussusception Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 3535 SummarySummary  IntussusceptionIntussusception is a rare, yet serious condition is a rare, yet serious condition in adultsin adults  May be a marker of pathological lesionMay be a marker of pathological lesion  Increase use of CT causing increased pickIncrease use of CT causing increased pick--up of up of transient transient intussusceptionintussusception  CT scan is most accurate method of CT scan is most accurate method of DxDx  Visualization is ideal because of nonVisualization is ideal because of non--specific signs and specific signs and symptomssymptoms  Target lesion on axial viewTarget lesion on axial view  Sausage shaped lesion on longitudinal viewSausage shaped lesion on longitudinal view Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 3636 AcknowledgementsAcknowledgements  Thank you to Dr. Kane for suggesting the index Thank you to Dr. Kane for suggesting the index case and to Dr. case and to Dr. StienStien for his help in interpreting for his help in interpreting the films.the films.  Thank you to Pamela Thank you to Pamela LepkowskiLepkowski for her for her technical help.technical help.  Thank you to Dr. Gillian Lieberman for her Thank you to Dr. Gillian Lieberman for her teaching and guidance.teaching and guidance.  Thank you to Larry Thank you to Larry BarbarbasBarbarbas, our Webmaster., our Webmaster. Sherry Farzan-Kashani, HMS III Gillian Lieberman, MD 3737 ReferencesReferences  AzarAzar T, Berger DL. Adult T, Berger DL. Adult IntussusceptionIntussusception. . Ann of Ann of SurgSurg 1997; 226(2):1341997; 226(2):134--138.138.  BegosBegos DG, DG, SandorSandor A, A, ModlinModlin IM. The Diagnosis and Management of Adult IM. The Diagnosis and Management of Adult IntussusceptionIntussusception. . Am J Am J SurgSurg 1997; 173: 881997; 173: 88--94. 94.  DanemanDaneman A, Navarro O. A, Navarro O. IntussusceptionIntussusception. . PediatrPediatr RadiolRadiol 2003; 33:792003; 33:79--85.85.  Feldman: Feldman: SleisengerSleisenger & & FordtranFordtran’’ss Gastrointestinal and Liver Disease, 7Gastrointestinal and Liver Disease, 7thth eded; p 2119; p 2119-- 2120.2120.  Gayer G, Gayer G, ApterApter S, Hofmann C, S, Hofmann C, NassNass S, S, AmitaiAmitai M, M, ZissinZissin R, Hertz M. R, Hertz M. IntussusceptionIntussusception in in Adults: CT Diagnosis. Adults: CT Diagnosis. Clinical RadiologyClinical Radiology 1998; 53: 531998; 53: 53--57.57.  Gayer, G, Gayer, G, ZissinZissin R, R, ApterApter S, Papa M, Hertz M. Adult S, Papa M, Hertz M. Adult IntussusceptionIntussusception –– a CT Diagnosis. a CT Diagnosis. Br J Br J RadiolRadiol 2002; 75(890): 1852002; 75(890): 185--190.190.  Grainger & Allison's Diagnostic Radiology: A Textbook of Medical Imaging, 4th Ed., p1214-1216.  Haas EM, Haas EM, EtterEtter EL, Ellis S, Taylor TV. Adult EL, Ellis S, Taylor TV. Adult intussusception.intussusception.A