Figure 1
Bowel-within-bowel
Bowel-within-bowel configuration - pathognomonic. The mesentery fat and vessels are seen inside the loop, following the intussusceptum.
Jejunal intussusception due to GIST
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsAbreu I., Donato H., Teixeira L., Moreira A., Caseiro-Alves F.
Connected authors
58 years, female
Clinical History
A female patient, 58 years old, presented in the emergency department with GI bleeding and weight loss since two/three months ago.
Hb: 6, 8 g/dL.
Upper GI endoscopy: ulcerated sub-epithelial lesion in the proximal jejunum, with 3 cm.
Hb: 6, 8 g/dL.
Upper GI endoscopy: ulcerated sub-epithelial lesion in the proximal jejunum, with 3 cm.
Imaging Findings
CT enterography (Fig.1-3) showed a hypervascular expansive lesion in the lumen of the proximal jejunum, with well-defined borders, measuring 3 cm. This lesion is the cause of jejuno-jenunal intussusception, which is characterized by a bowel-within-bowel configuration. There are no signs of GI obstruction, distant metastasis or adenopathies.
Discussion
Background:
Intussusception consists in the invagination of a bowel loop with its mesenteric fold (intussusceptum) into the lumen of a contiguous portion of bowel (intussuscipiens) due to the peristalsis [1]. Intussusceptions are classified according to location (enteroenteric, ileocolic, ileocecal, or colocolic), with or without a lead point, that may be benign or malignant [2].
GISTs are thought to originate from interstitial cells of Cajal located in the muscularis propria in the GI wall, and arise most commonly from the stomach (60%–70%), small bowel (30%) and rarely from the rectum, oesophagus, colon, and appendix [3].
Clinical Perspective:
Intussusception without a lead point may be asymptomatic or manifest as vague abdominal pain, and does not generally cause proximal bowel obstruction. Most cases are found incidentally at CT performed for other reasons [4].
Intussusception with a lead point may manifest with abdominal pain, nausea and vomiting, suggesting intestinal obstruction. However it can also manifest with symptoms
related to a neoplastic process (constipation, weight loss, GI bleeding) [4].
Imaging Perspective:
At abdominal CT, the appearance of bowel-within-bowel with or without mesenteric fat and vessels is pathognomonic for intussusception (Fig. 1). In a transversal view a target sign may be visible (Fig. 3). In recent years, abdominal CT has been reported to be the most useful tool for diagnosis of intestinal intussusception and the lead point, with a diagnostic accuracy of 58–100% [5].
With contrast-enhanced CT, GISTs appear as exophytic masses with peripheral enhancement. They may have heterogeneous enhancement depending on their level of aggressiveness, and the more aggressive GISTs may have a central area of necrosis (hypoattenuation areas) or areas of hemorrhage (high attenuation). Calcification is rare [6].
Outcome:
Surgery is the treatment of choice for GISTs, if resectable. Tyrosine kinase inhibitor (Imatinib) has produced a good response and prolonged survival in patients with advanced stage disease [6].
Our case underwent surgical treatment, without signs of recurrence at this time (1 year of follow up).
Take Home Message, Teaching Points:
- Intussusception consists in the invagination of a bowel loop with its mesenteric fold (intussusceptum) into the lumen of a contiguous portion of bowel (intussuscipiens) due to the peristalsis.
- The CT appearance of bowel-within-bowel with or without mesenteric fat and vessels is pathognomonic for intussusception.
- The lead point may be seen at CT, even though it is hard to discern the exact underlying disease in most cases.
Intussusception consists in the invagination of a bowel loop with its mesenteric fold (intussusceptum) into the lumen of a contiguous portion of bowel (intussuscipiens) due to the peristalsis [1]. Intussusceptions are classified according to location (enteroenteric, ileocolic, ileocecal, or colocolic), with or without a lead point, that may be benign or malignant [2].
GISTs are thought to originate from interstitial cells of Cajal located in the muscularis propria in the GI wall, and arise most commonly from the stomach (60%–70%), small bowel (30%) and rarely from the rectum, oesophagus, colon, and appendix [3].
Clinical Perspective:
Intussusception without a lead point may be asymptomatic or manifest as vague abdominal pain, and does not generally cause proximal bowel obstruction. Most cases are found incidentally at CT performed for other reasons [4].
Intussusception with a lead point may manifest with abdominal pain, nausea and vomiting, suggesting intestinal obstruction. However it can also manifest with symptoms
related to a neoplastic process (constipation, weight loss, GI bleeding) [4].
Imaging Perspective:
At abdominal CT, the appearance of bowel-within-bowel with or without mesenteric fat and vessels is pathognomonic for intussusception (Fig. 1). In a transversal view a target sign may be visible (Fig. 3). In recent years, abdominal CT has been reported to be the most useful tool for diagnosis of intestinal intussusception and the lead point, with a diagnostic accuracy of 58–100% [5].
With contrast-enhanced CT, GISTs appear as exophytic masses with peripheral enhancement. They may have heterogeneous enhancement depending on their level of aggressiveness, and the more aggressive GISTs may have a central area of necrosis (hypoattenuation areas) or areas of hemorrhage (high attenuation). Calcification is rare [6].
Outcome:
Surgery is the treatment of choice for GISTs, if resectable. Tyrosine kinase inhibitor (Imatinib) has produced a good response and prolonged survival in patients with advanced stage disease [6].
Our case underwent surgical treatment, without signs of recurrence at this time (1 year of follow up).
Take Home Message, Teaching Points:
- Intussusception consists in the invagination of a bowel loop with its mesenteric fold (intussusceptum) into the lumen of a contiguous portion of bowel (intussuscipiens) due to the peristalsis.
- The CT appearance of bowel-within-bowel with or without mesenteric fat and vessels is pathognomonic for intussusception.
- The lead point may be seen at CT, even though it is hard to discern the exact underlying disease in most cases.
Differential Diagnosis List
Jejunal intussusception induced by a GIST
Jejunal intussusception induced by a GIST
Jejunal intussusception induced by a carcinoid tumour
Jejunal intussusception induced by hypervascular metastases (melanoma or breast)
Final Diagnosis
Jejunal intussusception induced by a GIST
References
[1] Warshauer DM, Lee JK. (1999) Adult Intussusception Detected at CT or MR Imaging: Clinical-Imaging Correlation. Radiology Vol. 212:853-860 (PMID: 10478257)
[2] Begos DG, Sandor A, Modlin IM (1997) The diagnosis and management of adult intussusception. American Journal of Surgery Vol. 173, no. 2, pp. 88–94 (PMID: 9074370)
[3] Lee NK, Kim S, Kim GH, et al. (2010) Hypervascular Subepithelial Gastrointestinal Masses: CT-Pathologic Correlation. RadioGraphics Vol. 30:1915–1934 (PMID: 21057127)
[4] Kim YH, Blake MA, Harisinghani MG, et al. (2006) Adult Intestinal Intussusception: CT Appearances and Identification of a Causative Lead Point. RadioGraphics Vol. 26:733–744 (PMID: 16702451)
[5] M. Barussaud, N. Regenet, X. Briennon et al. (2006) Clinical spectrum and surgical approach of adult intussusceptions: a multicentric study. International Journal of Colorectal Disease Vol. 21, no. 8, pp. 834–839 (PMID: 15951987)
[6] Horwitz BM, Zamora E, Gallegos MP. (2011) Best cases from the AFIP: gastrointestinal stromal tumor of the small bowel. RadioGraphics Vol. 31:429–434 (PMID: 21415188)
Case information
| URL: | https://eurorad.org/case/12875 |
| DOI: | 10.1594/EURORAD/CASE.12875 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
Intussusception - coronal reformating
Bowel-within-bowel configuration - intussusception - in an extension of 10cm, with the lead point in an expansive hypervascular lesion with 3cm.
Figure 3
Target sign
Typical multilayered appearance of a small bowel intussusception. In this case, the lead point (hyper vascular lesion) is seen inside the loop.
Bowel-within-bowel
Bowel-within-bowel configuration - pathognomonic. The mesentery fat and vessels are seen inside the loop, following the intussusceptum.
CHUC, Coimbra, Portugal
CHUC, Coimbra, Portugal
Intussusception - coronal reformating
Bowel-within-bowel configuration - intussusception - in an extension of 10cm, with the lead point in an expansive hypervascular lesion with 3cm.
CHUC, Coimbra, Portugal
CHUC, Coimbra, Portugal
Target sign
Typical multilayered appearance of a small bowel intussusception. In this case, the lead point (hyper vascular lesion) is seen inside the loop.
CHUC, Coimbra, Portugal
CHUC, Coimbra, Portugal