View
215
Download
0
Category
Tags:
Preview:
Citation preview
Gastroenterology Grand Rounds
May 1, 2014Fellow: David Tang, M.D.
Faculty: Milena Gould, M.D.
Case Presentation• 61 year old White man• Bloating and constipation alternating with
diarrhea for 3 months.• No weight loss• No rectal bleeding
8/29/2012
Hgb 8.3
MCV 68
Ferritin 2.60
FIT Positive
Colonoscopy 12/14/2012
Polyp at 40 cm
Colonoscopy 12/14/2012
Mass at 45 cm
Colonoscopy 12/14/2012
Mass at 45 cm
Case Presentation
• Histology– Polyp at 40 cm Tubulovillous adenoma– Mass at 45 cm Invasive adenocarcinoma
• Staging CT scan showed mass in the descending colon and another large mass in the cecum.
Case Presentation
• Patient refused referral to Medical Oncology until June 2013
• He continued to suffer from intermittent abdominal pain, bloating, and diarrhea
• A repeat colonoscopy was performed to biopsy the cecal mass
Colonoscopy 7/11/2013
Sigmoid Mass #1
Colonoscopy 7/11/2013
Sigmoid Mass #2
Colonoscopy 7/11/2013
Descending Colon Mass
Colonoscopy 7/11/2013
“Ascending Colon Mass vs Extrinsic Compression”
Case Presentation
• Four days after colonoscopy, patient presented to EC with constant severe abdominal camps and pain associated with nausea and vomiting
Cecal mass
Terminal Ileum
Distal colon
Everted cecal wall
Courtesy of Dr. Zarrin-Khameh
Diagnosis
Intussusception of the cecum into the descending colon due to cecal adenocarinoma
Clinical Questions
• What is the incidence of adult intussusception?• What is the traditional understanding of the
etiology of adult intussusception?• How has CT changed our understanding of the
etiology and natural history of adult intussusception?
• Is there a role for endoscopy to treat adult intussusception?
Incidence of Adult Intussusception
• Cross-sectional study from Glasgow, UK estimated an annual incidence of 2 – 3 cases per 100,000 (<0.1% hospital admissions)
• Intussusception accounts for ~ 1% of adult patients with bowel obstruction
Nalmpantidis Ann Gastroenterol 2012Azar Ann Surg 1997
Etiology of Adult Intussusception
• Retrospective review of 58 patients collected from 1964 – 1993 at Massachusetts General Hospital
Azar Ann Surg 1997
Etiology of Adult Intussusception
Azar Ann Surg 1997
Etiology of Adult Intussusception
• Retrospective review of 22 cases of adult intussusception in Winnipeg, Canada hospital from 1989 – 2000.
Zubaidi Dis Colon Rectum 2006
Etiology of Adult Intussusception
Zubaidi Dis Colon Rectum 2006
Etiology of Adult Intussusception
• Retrospective review of 44 cases of adult intussusception in a Chinese hospital from 2001 to 2008.
Wang World J Gastroenterol 2006
Etiology of Adult Intussusception
Wang World J Gastroenterol 2006
Etiology of Adult Intussusception
Azar Ann Surg 1997Zubaidi Dis Colon Rectum 2006
Wang World J Gastroenterol 2006Eisen J Am Coll Surg 1999
Colonic Malignant Idiopathic N
Azar et al. 24% 46% 1.7% 58
Zubaidi et al. 27% 36% 13.6% 22
Wang et al. 20% 27% 9.1% 44
Eisen et al. 19% 44% 8% 27
Etiology of Adult Intussusception
Horton AJR 2008Berger NEJM 2000
• Crohn’s disease• Celiac disease• Giardiasis• HIV• Endometriosis
Etiology of Adult Intussusception
Felix Am J Surg 1976
Diagnosis of Adult Intussusception
• Retrospective review of 33 adults with 41 cases of intussusception on CT.
• 37 cases of small bowel involvement and 4 cases of colonic involvement– All 4 colonic cases had neoplastic lead point on
follow up– 29 cases (from 23 patients) of enteric involvement
had non – neoplastic lead points• 16 of 23 patients with idiopathic etiology
– None of these patients had recurrent intussusceptionWarshauer Radiology 1999
Diagnosis of Adult Intussusception
• Retrospective review of 37 patients with intussusception on CT and median 119 days of follow up
• Only 6 patients (17%) required surgery• 25 of these patients with “self-limiting”
intussusception– 13 of these patients without intussusception on
follow up imaging
Lvoff Radiology 2003
Diagnosis of Adult Intussusception
Lvoff Radiology 2003
Diagnosis of Adult Intussusception
• Multivariate, stepwise, logistic regression analysis showed that intussusception length was the only variable independently predictive of outcome, with an odds ratio of 1.57 (95% CI: 1.17 – 2.11).
• All 20 patients with intussusception length < 3.5 cm had self-limiting outcomes.
Lvoff Radiology 2003
Diagnosis of Adult Intussusception
• Retrospective review of 121 patients with 136 intussusceptions on CT
• 88% enteroenteric intussusceptions• Only 6% of intussusceptions required surgery• 2.5% of entroenteric intussusceptions treated
with surgery• Compared with 45% of colonic
intussusceptions treated with surgery
Lvoff Radiology 2003
Role of Endoscopy
Kitamura GIE 1990
44 year old woman with repeated episodes of abdominal pain, diarrhea, and vomiting.Barium enema showed a lipoma which was reduced with colonoscopy and later resected.
Role of Endoscopy
• Idiopathic prolapse of ileal mucosa through ileocecal valve mistaken for cecal mass on imaging and reduced with colonoscopy.
• One out of 13 patients identified on retrospective review from 1981 – 1994 underwent successful colonoscopic polypectomy of ileal lipoma with subsequent reduction.
Eu Singapore Med J 1994Begos Am J Surg 1997
Role of Endoscopy
Begos Am J Surg 1997
Role of Endoscopy
Brayton Am J Surg 1954
Thank You
Dr. Milena GouldDr. Neda Zarrin-Khameh
Dr. Juan Ibarra
Recommended