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Electronic Clinical Challenges and Images in GI
Electronic Clinical Challenges and Images in GI
Image 2
Question: A previously healthy 46-year-old woman was referred to the emergency room for a vague pain located within her right abdominal region that had started the previous night. Physical examination revealed tenderness over the right abdomen. The laboratory values were within normal limit, except for a mildly elevated serum glutamyl pyruvic transaminase level (74 U/L; normal range, 4 –38 U/L). A plain film radiograph examination of abdomen was carried out (Figure A). What is the diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal. org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. CHEN-TE CHOU Department of Radiology Chang-Hua Christian Hospital Erlin Branch and
Department of Biomedical Imaging and Radiological Science National Yang-Ming Medical University Taiwan YANG-YUAN CHEN Department of Gastroenterology Chang-Hua Christian Hospital Taiwan RAN-CHOU CHEN Department of Biomedical Imaging and Radiological Science National Yang-Ming Medical University Taiwan © 2009 by the AGA Institute
0016-5085/09/$36.00 doi:10.1053/j.gastro.2008.11.030
GASTROENTEROLOGY 2009;136:e3– e4
e4
GASTROENTEROLOGY Vol. 136, No. 1
Answer to the Clinical Challenges and Images in GI Question: Image 2: Cecocolic Intussusception Caused by an Appendiceal Mucocele The plain film revealed an intracolic mass in the ascending colon that seemed to be connected to the terminal ileum (long arrow), which was surrounded by the mesenteric fat. A rim calcification (short arrow) on the mass and a target sign (arrow head) surrounded the mass can be noted (Figure B). A coronal reformatted CT image showed a tubular mass with curvilinear calcification that gave rise to cecocolic intussusception together with secondary ileocolic intussusception (Figure C). Colonoscopy showed a reddish mass with intussusception in the ascending colon (Figure D). The patient underwent right hemicolectomy and the operative finding was identical to the colonoscopy and CT findings. The gross specimen revealed tubular dilatation of the appendix (Figure E, arrow). The histologic diagnosis was appendiceal cystadenoma with mucocele. The plain film x-ray of an appendiceal mucocele may show a soft tissue mass in the right lower quadrant with curvilinear calcification. The plain film of intussusception may show presence of an intracolic mass, a target sign, and this may be linked to the classic triad of intestinal obstruction, intracolic mass, and paucity of right lower quadrant gas. However, the specifically diagnostic findings are those of an intracolic mass or the target sign.1 Appendiceal mucoceles are found in only 0.2%–0.3% of all appendectomy materials and associated with intussusception is very uncommon. Appendiceal mucocele can be of 4 histologic subtypes: (1) a retention cyst caused by mechanical blockage, (2) mucosal hyperplasia, (4) cystadenoma, and (4) cystadenocarcinoma. If we exclude mechanical blockage, when hyperplasia, cystadenoma, and cystadenocarcinoma are considered, then cystadenoma comprise the majority of cases.2 Preoperative diagnosis of the appendiceal mucocele is important to avoid intraoperative rupture, which may lead to pseudomyxoma peritonei. Simple appendectomy is the choice in term of operative treatment for patients with a benign mucocele that has negative margins of resection without perforation. For patients with a perforated mucocele, with positive margins of resection, positive cytology, and positive appendiceal lymph nodes, right hemicolectomy with postoperative chemotherapy should be performed.3 In conclusion, although very rare, a precise preoperative diagnosis on plain film was possible because of the combination of well-known signs of intussusception and suggestive curvilinear calcification of the appendiceal mucocele itself. References 1. Hernandez JA, Swischuk LE, Angel CA. Validity of plain films in intussusception. Emerg Radiol 2004;10:323–326. 2. Zissin R, Gayer G, Kots E, et al. Imaging of mucocele of the appendix with emphasis on the CT findings: a report of 10 cases. Clin Radiol 1999;54:826 – 832. 3. Dhage-Ivatury S, Sugarbaker PH. Update on the surgical approach to mucocele of the appendix. J Am Coll Surg 2006;202:680 – 684.
Image 2
Question: A previously healthy 46-year-old woman was referred to the emergency room for a vague pain located within her right abdominal region that had started the previous night. Physical examination revealed tenderness over the right abdomen. The laboratory values were within normal limit, except for a mildly elevated serum glutamyl pyruvic transaminase level (74 U/L; normal range, 4 –38 U/L). A plain film radiograph examination of abdomen was carried out (Figure A). What is the diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal. org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. CHEN-TE CHOU Department of Radiology Chang-Hua Christian Hospital Erlin Branch and
Department of Biomedical Imaging and Radiological Science National Yang-Ming Medical University Taiwan YANG-YUAN CHEN Department of Gastroenterology Chang-Hua Christian Hospital Taiwan RAN-CHOU CHEN Department of Biomedical Imaging and Radiological Science National Yang-Ming Medical University Taiwan © 2009 by the AGA Institute
0016-5085/09/$36.00 doi:10.1053/j.gastro.2008.11.030
GASTROENTEROLOGY 2009;136:e3– e4
e4
GASTROENTEROLOGY Vol. 136, No. 1
Answer to the Clinical Challenges and Images in GI Question: Image 2: Cecocolic Intussusception Caused by an Appendiceal Mucocele The plain film revealed an intracolic mass in the ascending colon that seemed to be connected to the terminal ileum (long arrow), which was surrounded by the mesenteric fat. A rim calcification (short arrow) on the mass and a target sign (arrow head) surrounded the mass can be noted (Figure B). A coronal reformatted CT image showed a tubular mass with curvilinear calcification that gave rise to cecocolic intussusception together with secondary ileocolic intussusception (Figure C). Colonoscopy showed a reddish mass with intussusception in the ascending colon (Figure D). The patient underwent right hemicolectomy and the operative finding was identical to the colonoscopy and CT findings. The gross specimen revealed tubular dilatation of the appendix (Figure E, arrow). The histologic diagnosis was appendiceal cystadenoma with mucocele. The plain film x-ray of an appendiceal mucocele may show a soft tissue mass in the right lower quadrant with curvilinear calcification. The plain film of intussusception may show presence of an intracolic mass, a target sign, and this may be linked to the classic triad of intestinal obstruction, intracolic mass, and paucity of right lower quadrant gas. However, the specifically diagnostic findings are those of an intracolic mass or the target sign.1 Appendiceal mucoceles are found in only 0.2%–0.3% of all appendectomy materials and associated with intussusception is very uncommon. Appendiceal mucocele can be of 4 histologic subtypes: (1) a retention cyst caused by mechanical blockage, (2) mucosal hyperplasia, (4) cystadenoma, and (4) cystadenocarcinoma. If we exclude mechanical blockage, when hyperplasia, cystadenoma, and cystadenocarcinoma are considered, then cystadenoma comprise the majority of cases.2 Preoperative diagnosis of the appendiceal mucocele is important to avoid intraoperative rupture, which may lead to pseudomyxoma peritonei. Simple appendectomy is the choice in term of operative treatment for patients with a benign mucocele that has negative margins of resection without perforation. For patients with a perforated mucocele, with positive margins of resection, positive cytology, and positive appendiceal lymph nodes, right hemicolectomy with postoperative chemotherapy should be performed.3 In conclusion, although very rare, a precise preoperative diagnosis on plain film was possible because of the combination of well-known signs of intussusception and suggestive curvilinear calcification of the appendiceal mucocele itself. References 1. Hernandez JA, Swischuk LE, Angel CA. Validity of plain films in intussusception. Emerg Radiol 2004;10:323–326. 2. Zissin R, Gayer G, Kots E, et al. Imaging of mucocele of the appendix with emphasis on the CT findings: a report of 10 cases. Clin Radiol 1999;54:826 – 832. 3. Dhage-Ivatury S, Sugarbaker PH. Update on the surgical approach to mucocele of the appendix. J Am Coll Surg 2006;202:680 – 684.