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Multiple small-bowel intussusceptions caused by metastatic lung cancers
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Multiple small-bowel intussusceptions caused by metastatic lung cancers Yan-Jiun Huang, MD, Ming-Hsun Wu, MD, and Ming-Tsan Lin, MD, PhD, Taipei, Taiwan From the Department of Surgery, National Taiwan University Hospital, Taipei
A 78-year-old man with underlying disease of rheumatic heart disease status post-mitral valve replacement 20 years previous presented to the emergency room with intermittent epigastragia and black, loose stools. Laboratory studies showed a white cell count of 11830 per cubic millimeter, C-reactive protein level of 4.68 mg/dl, and stool occult blood of 3⫹. Chest x-ray showed a right upper lobe lung tumor, and abdominal echography showed distended small-bowels and multiple pseudokidney signs (Fig 1). Computed tomography showed bowel-wall thickening of the small intestine with a telescoping-like appearance at the left lower quadrant of the abdomen (Fig 2). During gasless laparoscopy-assisted minilaparotomy, multiple intussusceptions caused by small-bowel metastatic tumors were noted; the total involved length was greater than 30 cm (Fig 3). The patient was treated with segmental resection, and the postoperative course was uneventful. The small-bowel tumors were pathologically confirmed from the matastatic poorly differentiated carcinoma from lung cancer.
Accepted for publication August 13, 2006. Reprint requests: Dr Ming-Tsan Lin, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan. E-mail: [email protected]. Surgery 2008;143:148-9. 0039-6060/$ - see front matter © 2008 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2006.08.014
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Fig 1. Abdominal echogram showing pseudokidney signs (red arrows).
DISCUSSION The cause of intussusception differs between pediatric and adult populations. In children, a precipitating lesion is found in only 10% of patients, whereas in adults, an underlying cause is present 90% of the time. Intestinal intussusception caused by metastatic tumors, however, is uncommon. Symptomatic small-bowel metastases from lung cancer have rarely been reported. Most reported cases of small-bowel metastases from primary lung cancer initially present as obstruction, perforation, or gastrointestinal bleeding.1 Our patient presented with an unusual complication of lung cancer metastasis: intussusception of the small bowel. Also present was the symptomatic triad of intussusception (ie, abdominal pain, abdominal distention, and vomiting).
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Fig 2. Abdominal computed tomography showing one segment of small bowel telescoping into another (red arrows).
Recent reports have shown that computed tomography is the most useful imaging tool in making a preoperative diagnosis of intussusception.1 With computed tomography, a bowel-in-bowel appearance, suggested by mesenteric fat and vessel stuck in between the walls of the small bowel, is pathognomonic.2,3 Abdominal sonography may help diagnose adult intussusception with the imaging appearance of pseudokidney signs or the target sign as we have described.
Fig 3. Intraoperative imaging showing multiple regions of intussusceptions (red arrows). REFERENCES 1. Berg A, Cellier C, Daniel C, et al. Small bowel metastases from primary carcinoma of the lung. Am Coll of Gastroenterology 1999;94:1884-7. 2. Katz ME, Hahn IS, Job GG, Toole AL. Intussusception as an unusual complication of metastatic lung cancer. 1981;45: 220-2. 3. Tan KY, Tan SM, Tan AGS, Chen CYY, Chen HC, Hoe MNY. Adult intussusception: experience in Singapore. Austral NZ J Surg 2003;73:1044-7.
Multiple small-bowel intussusceptions caused by metastatic lung cancers Yan-Jiun Huang, MD, Ming-Hsun Wu, MD, and Ming-Tsan Lin, MD, PhD, Taipei, Taiwan From the Department of Surgery, National Taiwan University Hospital, Taipei
A 78-year-old man with underlying disease of rheumatic heart disease status post-mitral valve replacement 20 years previous presented to the emergency room with intermittent epigastragia and black, loose stools. Laboratory studies showed a white cell count of 11830 per cubic millimeter, C-reactive protein level of 4.68 mg/dl, and stool occult blood of 3⫹. Chest x-ray showed a right upper lobe lung tumor, and abdominal echography showed distended small-bowels and multiple pseudokidney signs (Fig 1). Computed tomography showed bowel-wall thickening of the small intestine with a telescoping-like appearance at the left lower quadrant of the abdomen (Fig 2). During gasless laparoscopy-assisted minilaparotomy, multiple intussusceptions caused by small-bowel metastatic tumors were noted; the total involved length was greater than 30 cm (Fig 3). The patient was treated with segmental resection, and the postoperative course was uneventful. The small-bowel tumors were pathologically confirmed from the matastatic poorly differentiated carcinoma from lung cancer.
Accepted for publication August 13, 2006. Reprint requests: Dr Ming-Tsan Lin, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan. E-mail: [email protected]. Surgery 2008;143:148-9. 0039-6060/$ - see front matter © 2008 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2006.08.014
148 SURGERY
Fig 1. Abdominal echogram showing pseudokidney signs (red arrows).
DISCUSSION The cause of intussusception differs between pediatric and adult populations. In children, a precipitating lesion is found in only 10% of patients, whereas in adults, an underlying cause is present 90% of the time. Intestinal intussusception caused by metastatic tumors, however, is uncommon. Symptomatic small-bowel metastases from lung cancer have rarely been reported. Most reported cases of small-bowel metastases from primary lung cancer initially present as obstruction, perforation, or gastrointestinal bleeding.1 Our patient presented with an unusual complication of lung cancer metastasis: intussusception of the small bowel. Also present was the symptomatic triad of intussusception (ie, abdominal pain, abdominal distention, and vomiting).
Huang, Wu, and Lin 149
Surgery Volume 143, Number 1
Fig 2. Abdominal computed tomography showing one segment of small bowel telescoping into another (red arrows).
Recent reports have shown that computed tomography is the most useful imaging tool in making a preoperative diagnosis of intussusception.1 With computed tomography, a bowel-in-bowel appearance, suggested by mesenteric fat and vessel stuck in between the walls of the small bowel, is pathognomonic.2,3 Abdominal sonography may help diagnose adult intussusception with the imaging appearance of pseudokidney signs or the target sign as we have described.
Fig 3. Intraoperative imaging showing multiple regions of intussusceptions (red arrows). REFERENCES 1. Berg A, Cellier C, Daniel C, et al. Small bowel metastases from primary carcinoma of the lung. Am Coll of Gastroenterology 1999;94:1884-7. 2. Katz ME, Hahn IS, Job GG, Toole AL. Intussusception as an unusual complication of metastatic lung cancer. 1981;45: 220-2. 3. Tan KY, Tan SM, Tan AGS, Chen CYY, Chen HC, Hoe MNY. Adult intussusception: experience in Singapore. Austral NZ J Surg 2003;73:1044-7.