Gastroenterology
Volume 134, Issue 1 , Page 20, January 2008

Clinical Challenges and Images in GI

James Whitcomb Riley Hospital For Children, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana

Article Outline

 

Back to Article Outline

Image 2 

Question: A previously healthy 5-1/2-year-old Amish boy presented with a 2-week history of maroon-colored, soft stool and intermittent, crampy, lower abdominal pain. The family denied diarrhea or fevers. The birth history, past medical history, family history, and social history were unrevealing, except for a recent family trip to a lake where the child had swum. On physical examination he appeared pale and thin. His stool was hemoccult positive. The remainder of the examination, including perianal inspection, was unremarkable. Laboratory studies were significant for microcytic anemia (hemoglobin, 7.9 g/dL; mean corpuscular volume, 66.6 fL), and an erythrocyte sedimentation rate of 28 mm/hr. The C-reactive protein was 0.5 mg/dL. On colonoscopy, a smooth surfaced mass was noted at the hepatic flexure (Image A). The mass filled the lumen and appeared to be covered by edematous mucosa. Computed tomography (CT) was performed to further evaluate the endoscopic impression (Image B). What is the diagnosis?

Look on page 373 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Back to Article Outline

Answer to the Clinical Challenges and Images in GI Question: Image 2 (page 20): Ileocolic intussusception caused by Burkitt’s lymphoma 

The endoscopic findings made us suspect an intussusception; the smooth appearance of the mass covered by edematous mucosa was not suggestive of a polyp. The intussusception was confirmed by abdominal CT scan (Image B). The typical appearance of ileocolic intussusception was seen in the ascending colon with the classic finding of an intraluminal mass (the intussuscipiens) with eccentrically located fat. A discrete lead point could not be seen on the CT scan, although given the patient’s age, we suspected a pathologic lead point. Radiologic reduction of the intussusception was not attempted owing to the possibility of a lead point and the chronicity of symptoms. The intussusception was unable to be reduced surgically, and a limited resection of the ileal margin, cecum, and appendix (5.5 × 3.8 cm) was performed followed by an ileocolic anastomosis. Histologic examination of the resected tissue revealed diffuse infiltration of large, atypical lymphoid cells with a background imparting a “starry sky” appearance, consistent with Burkitt’s lymphoma (Image C). The patient is doing well following tumor resection and treatment with vincristine, doxorubicin, and cyclophosphamide.

Intussusception is an emergent condition and should be included in the differential diagnosis of lower gastrointestinal bleeding in children. The classic triad of colicky abdominal pain, “red currant jelly” stools, and a palpable mass is present in <50% of cases.1 Intussusception in older children and adults may be more insidious and present with a variety of acute, intermittent, or chronic symptoms.2, 3 Presenting symptoms do not distinguish idiopathic intussusception from those with a lead point.1 Although one should be vigilant in evaluating for a pathologic lead point at any age, it is important to note that the likelihood of a lead point increases with age beyond infancy. It has been reported that approximately 5% of infants with intussusception have a lead point, in contrast with 60% of patients in the 5- to 14-year-old age group and up to 90% of adults with intussusception.1 Common lead points in children include hamartomatous polyps (as in Peutz–Jeghers syndrome), Meckel’s diverticulum, duplication cysts, and non-Hodgkin’s lymphoma.4 Burkitt’s lymphoma comprises about one half of all childhood lymphomas in the United States, usually manifesting at extranodal sites such as the ileocecal region, ovaries, kidneys, or breasts.5 This case reminds us that (1) nonspecific abdominal pain combined with bloody stool should heighten suspicion for intussusception, and (2) the likelihood of a pathologic lead point, including malignancy, is higher in older patients with intussusception.

Back to Article Outline

References 

  1. Blakelock RT, Beasley SW. The clinical implications of non-idiopathic intussusception. Pediatr Surg Int. 1998;14:163–167
  2. Azar T, Berger DL. Adult intussusception. Ann Surg. 1997;226:134–138
  3. Felix EL, Cohen MH, Berstein AD, et al. Adult intussusception: case report of recurrent intussusception and review of the literature. Am J Surg. 1976;131:758–791
  4. Navarro O, Daneman A. Intussusception part 3: diagnosis and management of those with an identifiable or predisposing cause and those that reduce spontaneously. Pediatr Radiol. 2004;34:305–312
  5. Jaffe E, Pittaluga S. In:  Hoffman R,  Benz EJ,  Shattil SJ, et al. editor. Hematology: Basic Principles and Practice. 4th ed.. New York: Churchill Livingstone; 2005;p. 1386–1387

 For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).

PII: S0016-5085(07)02120-8

doi:10.1053/j.gastro.2007.11.042

Gastroenterology
Volume 134, Issue 1 , Page 20, January 2008

Article Tools