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Electronic Clinical Challenges and Images in GI
Electronic Clinical Challenges and Images in GI
Image 2
Question: A 66-year-old man presented with a 3-day history of increasing nausea, vomiting, and crampy epigastric pain on a background of 2 to 3 months of intermittent abdominal pain. His past history included bilateral inguinal hernia repair and an umbilical hernia repair. One month previously he underwent a gastroscopy, which showed chronic active gastritis and a colonoscopy with ileal intubation that was normal apart from a 5-mm tubulovillous adenoma. Two days before admission, he had an abdominal ultrasound, which demonstrated a tender area corresponding to a bowel loop in the central abdomen. On examination, his abdomen was slightly distended, with paraumbilical tenderness. He had no guarding or rebound. There were no herniae palpable. Rectal examination and rigid sigmoidoscopy were normal. Liver function tests, lipase values, and white blood cell counts were normal. Abdominal x-ray (Figure A) demonstrated dilated loops of small bowel with air–fluid levels and absence of gas in the
colon. Abdominal computed tomography (CT; Figures B–D) was performed and the patient underwent laparoscopy (Video). What is the most likely diagnosis in this patient? See the GASTROENTEROLOGY web site (www. gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. HAMISH SHILTON, MBBS ANTHONY LONGANO, MBBS DANIEL G. CROAGH, MBBS, PhD, FRACS Department of Surgery Monash Medical Centre Clayton, Australia
© 2009 by the AGA Institute
0016-5085/09/$36.00 doi:10.1053/j.gastro.2008.09.007 GASTROENTEROLOGY 2009;136:e3– e4
e4
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI
GASTROENTEROLOGY Vol. 136, No. 3
Answer to the Clinical Challenges and Images in GI Question: Image 2: An Unusual Cause of Small Bowel Obstruction CT demonstrated dilated loops of small bowel, “swirling” of the mesentery, and a possible intraluminal soft tissue mass in the terminal ileum, consistent with intussusception. Laparoscopy revealed an ileocecal intussusception with the terminal ileum and its characteristic antimesenteric fold of fat not evident because it was buried deep within the right colon, consistent with progression of the intussusception from the previous CT scan. Laparotomy and right hemicolectomy were then performed. The lead point was a polyp of the terminal ileum measuring 35 mm in greatest dimension (Figure E). Microscopic examination of the polyp revealed an ulcerated surface and an underlying diffuse infiltrate of malignant cells (Figure F). Immunohistochemical staining of the tumour cells was negative for markers of epithelial, gastrointestinal stromal tumor, and plasma cell differentiation and was positive for B-cell marker CD20 (Figure G) and a diagnosis of diffuse, large, B-cell lymphoma was made. The patient made an uncomplicated postoperative recovery apart from a minor wound infection treated with simple drainage and antibiotics. Chest CT and bone marrow biopsy were later performed to complete the staging and the patient went on to have chemotherapy. Intussusception is an uncommon cause of small bowel obstruction in adults1; however, it must be considered when the more common causes have been eliminated, including adhesions, incarcerated hernia, and cecal tumors. In adults, intussusception is usually associated with a pathologic and often malignant lead point.2 Therefore en bloc resection (either open or laparoscopic) without reduction is the appropriate treatment.3 References 1. Coleman MJ, Hugh TB, May RE, et al. Intussusception in the adult. Aust N Z J Surg 1981;51:179 –180. 2. Azar T, Berger DL. Adult intussusception. Ann Surg 1997;226:134 –138. 3. Chiu CC, Wei PL, Huang MT, et al. Laparoscopic treatment of ileocecal intussusception caused by primary ileal lymphoma. Surg Laparosc Endosc Percutan Tech 2004;14:93–95.
Image 2
Question: A 66-year-old man presented with a 3-day history of increasing nausea, vomiting, and crampy epigastric pain on a background of 2 to 3 months of intermittent abdominal pain. His past history included bilateral inguinal hernia repair and an umbilical hernia repair. One month previously he underwent a gastroscopy, which showed chronic active gastritis and a colonoscopy with ileal intubation that was normal apart from a 5-mm tubulovillous adenoma. Two days before admission, he had an abdominal ultrasound, which demonstrated a tender area corresponding to a bowel loop in the central abdomen. On examination, his abdomen was slightly distended, with paraumbilical tenderness. He had no guarding or rebound. There were no herniae palpable. Rectal examination and rigid sigmoidoscopy were normal. Liver function tests, lipase values, and white blood cell counts were normal. Abdominal x-ray (Figure A) demonstrated dilated loops of small bowel with air–fluid levels and absence of gas in the
colon. Abdominal computed tomography (CT; Figures B–D) was performed and the patient underwent laparoscopy (Video). What is the most likely diagnosis in this patient? See the GASTROENTEROLOGY web site (www. gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. HAMISH SHILTON, MBBS ANTHONY LONGANO, MBBS DANIEL G. CROAGH, MBBS, PhD, FRACS Department of Surgery Monash Medical Centre Clayton, Australia
© 2009 by the AGA Institute
0016-5085/09/$36.00 doi:10.1053/j.gastro.2008.09.007 GASTROENTEROLOGY 2009;136:e3– e4
e4
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI
GASTROENTEROLOGY Vol. 136, No. 3
Answer to the Clinical Challenges and Images in GI Question: Image 2: An Unusual Cause of Small Bowel Obstruction CT demonstrated dilated loops of small bowel, “swirling” of the mesentery, and a possible intraluminal soft tissue mass in the terminal ileum, consistent with intussusception. Laparoscopy revealed an ileocecal intussusception with the terminal ileum and its characteristic antimesenteric fold of fat not evident because it was buried deep within the right colon, consistent with progression of the intussusception from the previous CT scan. Laparotomy and right hemicolectomy were then performed. The lead point was a polyp of the terminal ileum measuring 35 mm in greatest dimension (Figure E). Microscopic examination of the polyp revealed an ulcerated surface and an underlying diffuse infiltrate of malignant cells (Figure F). Immunohistochemical staining of the tumour cells was negative for markers of epithelial, gastrointestinal stromal tumor, and plasma cell differentiation and was positive for B-cell marker CD20 (Figure G) and a diagnosis of diffuse, large, B-cell lymphoma was made. The patient made an uncomplicated postoperative recovery apart from a minor wound infection treated with simple drainage and antibiotics. Chest CT and bone marrow biopsy were later performed to complete the staging and the patient went on to have chemotherapy. Intussusception is an uncommon cause of small bowel obstruction in adults1; however, it must be considered when the more common causes have been eliminated, including adhesions, incarcerated hernia, and cecal tumors. In adults, intussusception is usually associated with a pathologic and often malignant lead point.2 Therefore en bloc resection (either open or laparoscopic) without reduction is the appropriate treatment.3 References 1. Coleman MJ, Hugh TB, May RE, et al. Intussusception in the adult. Aust N Z J Surg 1981;51:179 –180. 2. Azar T, Berger DL. Adult intussusception. Ann Surg 1997;226:134 –138. 3. Chiu CC, Wei PL, Huang MT, et al. Laparoscopic treatment of ileocecal intussusception caused by primary ileal lymphoma. Surg Laparosc Endosc Percutan Tech 2004;14:93–95.