A RARE SITE OF BOWEL WITHIN BOWEL

ABSTRACT ID IRIA 1067 A RARE SITE OF BOWEL WITHIN BOWELIntussusception is telescoping of proximal bowel segment of gastrointestinal tract within the lumen of the adjacent segment.

It is a rare condition in adults, approximately 5-10% of all intussusceptions. Common occuring location are entero-enteric / ileo-colic / ileo-caecal / colo-colic.

Duodeno-jejunal intussusception location is unusual and secondary to duodenal tumour is an uncommon entity.

BACKGROUNDDuodenal intussusception is less frequent than intussusception of small intestine because of the fixed retroperitoneal duodenal position.

A lead point in intussusception involving the small bowel is generally due to benign pathology, in adults it is often related to the malignant condition.

More often benign tumour act as a lead point for intussusception because they are more mobile.

Few reported tumours of duodenum are lipoma, papilloma, fibroadenoma, carcino-liposarcoma, and Brunner gland hamartoma

ETIOLOGIES :

--Intraluminal : any intraluminal mass, eg : Pedunculated tumour

-- Intramural : Abnormality of bowel wall, eg : Sessile malignancy

-- Extraluminal : external mass causing area of abnormal peristalsis, eg : Inflamed appendix

CLINICAL FINDINGS:

Adults present with

--Crampy abdominal pain/ Abdominal distention/Constipation

--Nausea and Vomiting/ haematochezia/ malaena

--Signs: Palpable mass, tenderness over abdomenA 45 years old female came with complaints of,

Abdominal pain for 2 months radiating to back.

Abdominal distension.

No fever / constipation / vomiting.

Not k/c/o diabetes mellitus / hypertension.

CASE REPORTEXAMINATION: - Afebrile. Vitals stable. - No pallor/icterus/cyanosis/clubbing/pedal edema/lymphadenopathy

SYSTEMIC EXAMINATION:- CVS / CNS / RS : no abnormality detected- P/A : Tenderness over epigastric region INVESTIGATIONS:UGI SCOPY Fundal erosive gastritis with duodenal polyp. Biopsy of the polyp High grade dysplasia. PROVISIONAL DIAGNOSIS : EROSIVE GASTRITIS / DUODENAL POLYP

Duodenography showing abrupt narrowing at the 2nd part of duodenum.DUODENOGRAPHY

Ultrasound showing the typical bowel-within-bowel appearance TARGET SIGN (Fig A) and SANDWICH SIGN (Fig B & C) in the epigastric region and presence of vascularity in the intussuscepiens.USG

COMPUTED TOMOGRAPHY

Plain CT showing a well defined lobulated isodense lesion and is continuous along with the jejunal loop which on post-contrast study shows evidence of bowel within bowel configuration suggesting intussusception of the duodenal loop (probably the 3rd and 4th part of duodenum)into the proximal jejunum for a length of approx. 9-10cms.Post-contrast sagittal CT image showing the distal end of the jejunal loop (intussuscepiens) which appears thickened.Post-contrast axial CT image showing a well delineated intraluminal soft tissue lesion in the thickened jejunal loop with homogeneous enhancement possibly a polyp (red arrow).

Video clip showing the bowel-within-bowel pattern in the duodeno-jejunal junction.Duodenography: Showing abrupt narrowing at the 2nd part of duodenum.

Ultrasound: showing the classical TARGET SIGN and SANDWICH SIGN in the epigastric region.

CT: Showing BOWEL-WITHIN-BOWEL APPEARANCE involving the 3rd and 4th part of duodenum (intussusceptum) into the proximal jejunal loop (intussuscepiens) with a possible polypoid lesion in the jejunum.

IMAGING DIAGNOSISSurgical reduction of the intussusception with resection of the polypoid lesion arising from the duodenum was done.The lesion was sent for histopathological examination.

MANAGEMENTHISTOPATHOLOGICAL REPORTLong fronds of papillary / villous projections arising directly from mucosal surface of duodenum suggestive of DUODENAL VILLOUS ADENOMA. This case is reported for its rarity in adults in this location.

Only very few cases has been reported with associated villous adenoma as a causating tumour.

Radiologists should be familiar with CT appearances and be well trained in the identification of a causative lead point.

CONCLUSIONChuang, JH and Chen, WJ.Duodenojejunal intussusception secondary to hamartomatous polyp of Brunner's glands.J Pediatr Gastroenterol Nutr.1991;13:96100

Hutchinson, J.A successful case of abdominal section for intussusception.Proc R Med Chir Soc.1873;7:195Swischuk, LE, Hayden, CK, and Boulden, T.Intussusception: Indications for ultrasonography and an explanation of the doughnut and pseudokidney signs.Pediatr Radiol.1985;15:388391

Parienty, RA, Lepreux, JF, and Gruson, B.Sonographic and CT features of ileocolic intussusception.Am J Roentgenol.1981;136:608610

Van Beers, B, Trigaux, JP, and Pringot, J.Duodenojejunal intussusception secondary to duodenal tumors.Gastrointest Radiol.1988;13:2426

Knight, CD and Black, BM.Duodenojejunal intussusception due to lipoma: Report of a case.Mayo Clin Proc.1951;26:320323

Orenstein, HH, David, I, and Lorieo, D.Villous adenoma of the duodenum producing intussusception.Arch Surg.1984;119:487

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