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The target sign in bowel obstruction

Published:February 24, 2017DOI:https://doi.org/10.1016/j.ejim.2017.02.014

      Keywords

      1. Case history

      A 64 year old man presented with vomiting and colicky right upper abdominal pain radiating to his back. He had had these symptoms intermittently for three months, but they had acutely worsened over the last three days. He had undergone a total nephrectomy for a right sided renal tumour six years ago but had subsequently discharged from oncology follow-up. There was no other relevant past medical history.
      Physical examination revealed tenderness over the right upper quadrant but no peritonism. Normal bowel sounds were present. Abdominal radiographs showed a couple of borderline dilated small bowel loops. Serology revealed mildly raised C-reactive protein (76 mg/L), but normal liver function and amylase.
      He was initially managed as biliary colic, but a subsequent abdominal ultrasound was reported as normal. He continued to become progressively unwell with recurrent vomiting and worsening central abdominal discomfort. Computed tomography (CT) of the abdomen and pelvis was obtained for further investigation (See Fig. 1).
      Fig. 1
      Fig. 1Axial and coronal slice abdominal CT with IV contrast demonstrated a target sign and sausage shaped soft tissue mass respectively.

      2. What is the diagnosis?

      Abdominal CT confirmed an entero-enteric intussusception and the patient proceeded to have exploratory laparotomy. At surgery jejuno-jejunal intussusception was confirmed and reduced using a toothpaste maneuver. A small segment of unviable jejunum was excised with an end-to-end bowel anastomosis. A small 11 mm tumour was identified in the excised bowel segment. This was confirmed as metastatic renal cell carcinoma on subsequent histopathological examination.
      Intussusception is uncommon in adults, accounting for less than 5% of bowel obstruction presentations [
      • Marinis A.
      • Yiallourou A.
      • Samanides L.
      • Dafnios N.
      • et al.
      Intussusception of the bowel in adults: a review.
      ]. Unlike in children, in adults intussusception rarely presents acutely and is related to an underlying condition in up to 90%. Symptoms include abdominal pain, distension, nausea and vomiting which are often present for weeks.
      Most cases of adult intussusception involve small bowel and are usually related to benign pathology such as coeliac disease, bowel adhesions, lipomas, lymphoid hyperplasia and Meckel's diverticulae. Colonic intussusception, on the other hand, can have a malignant aetiology in up to 60% of cases, commensurate with the increased prevalence of colonic adenocarcinoma [
      • Kim Y.H.
      • Blake M.A.
      • Harisinghani M.G.
      • Archer-Arroyo K.
      • et al.
      Adult intussusception: CT appearances and identification of a causative lead point.
      ].
      CT appearances are pathognomonic, classically demonstrating a soft tissue mass constituted of superimposed bowel lumens peripherally with central fat density and vessels representing intussuscepted mesentery. When imaged axially this has a classic “target” sign while it can appear like a sausage-shaped mass longitudinally, as seen in the current case [
      • Gayer G.
      • Zissin R.
      • Apter S.
      • Papa M.
      • et al.
      Adult intussusception – a CT diagnosis.
      .
      The patient underwent restaging thoracic CT for consideration of chemotherapy treatment.

      Conflicts of interest

      None declared.

      Patient consent

      Obtained in writing.

      Acknowledgements

      We would like to acknowledge Dr. Alma Octavia Iacob for her contributions to the first draft of this article.

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        Adult intussusception: CT appearances and identification of a causative lead point.
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        Adult intussusception – a CT diagnosis.
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