Download pptx - Gastroenterology Grand Rounds May 1, 2014 Fellow: David Tang, M.D. Faculty: Milena Gould, M.D

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


Mass at 45 cm


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


Sigmoid Mass #1


Sigmoid Mass #2


Descending Colon Mass


“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


Azar Ann Surg 1997


• Retrospective review of 22 cases of adult intussusception in Winnipeg, Canada hospital from 1989 – 2000.

Zubaidi Dis Colon Rectum 2006


Zubaidi Dis Colon Rectum 2006


• Retrospective review of 44 cases of adult intussusception in a Chinese hospital from 2001 to 2008.

Wang World J Gastroenterol 2006


Wang World J Gastroenterol 2006


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


Horton AJR 2008Berger NEJM 2000

• Crohn’s disease• Celiac disease• Giardiasis• HIV• Endometriosis


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


• 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




• 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.



• 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


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