Bloody Diarrhea and Pain in a Potentially Deadly Abdominal Condition: Case Quiz

A 57-year-old woman presents to the emergency department (ED) with a 3-day history of colicky lower abdominal pain and diarrhea. She describes 4-5 episodes a day of soft diarrhea with blood mixed throughout. She denies having any fever, vomiting, or pain with defecation. Her last bowel movement occurred a few hours before her arrival to the ED. She also mentions having multiple intermittent episodes of bloody diarrhea (of lesser severity) over the past several months. An abdominal radiograph is ordered in triage (shown). Image courtesy of Wikimedia Commons.

How should the patient's diarrhea be classified?
A. Acute
B. Persistent
C. Chronic

Answer: C. Chronic

Diarrhea can be classified as acute, persistent (lasting for 2 weeks or longer), or chronic (persisting for longer than 1 month).^[1] Although the patient's current episode has lasted 3 days, she has been experiencing these symptoms for several months; therefore, the diarrhea can be classified as chronic.

The patient's medical history is notable only for a cesarean section. She takes no regular medications and denies having any allergies. She has a 30-pack year smoking history and drinks alcohol on the weekends only. Her vital signs are shown.

The patient is in no acute distress. Her abdomen is mildly distended with decreased bowel sounds. No guarding, rigidity, or rebound tenderness is noted. The rectal examination reveals noninflamed and nonswollen external hemorrhoids with guaiac-positive stool. The rest of the examination is unremarkable.

A laboratory panel with complete blood cell count, basic metabolic panel, liver function tests, coagulation studies, serum amylase and lipase levels, and urinalysis is performed. The abnormal values are shown.

What is the next diagnostic step?
A. Right upper quadrant ultrasound
B. CT scan of the abdomen and pelvis
C. Colonoscopy
D. Stool culture

Answer: B. CT scan of the abdomen and pelvis

The radiograph shows air-fluid levels with no air in the rectum. One goal is to rule out a bowel obstruction. Given the high suspicion for intra-abdominal pathology, the fact that the most common cause of obstruction in adults is a malignancy, and the concerning findings on the abdominal radiograph, a CT scan of the abdomen and pelvis would provide the greatest yield of diagnostic information in the shortest time. A representative contrast-enhanced CT axial section is shown.

What is the principal abnormality identified on the CT scan?
A. Intussusception
B. Diverticulitis
C. Toxic megacolon
D. Superior mesenteric artery occlusion

Answer: A. Intussusception

The CT scan demonstrates a segment of large bowel invaginating into a distal segment (red arrow) from an intussusception. The proximal intussusceptum is filled with oral contrast material (blue arrow), while the distal intussuscipiens contains no contrast material (yellow arrow). Mesenteric fat and vessels can be noted between the intussusceptum and intussuscipiens (white arrow).

Intussusceptions are classified according to location; they may be classified as enteroenteric, ileocolic, ileocecal, or colocolic. Most cases in adults involve the small bowel or a combination of the small and large bowels. In adults, colocolic intussusception occurs in less than 20% of cases.^[2,3] A sagittal reformatted CT scan from the patient demonstrates the telescoping nature of the intussusception (arrow).

The development of an intussusception may be idiopathic or from a lead point. Most cases involving the small bowel in adults, or any location in a pediatric patient, are idiopathic; however, involvement of the large bowel is usually from an intraluminal lead point. The most common benign lead points are adhesions, lipomas, and adenomatous polyps. This CT scan shows an intussusception caused by a large lipoma (arrow). Unfortunately, one half of cases of adult colocolic intussusceptions are from malignant lead points, such as adenocarcinoma, lymphoma, or metastases.^[1,2] Image courtesy of Radiopaedia.

Other, less commonly reported causes of adult intussusception include endometriosis, drug-related enterocolic lymphocytic phlebitis, mesenteric lymphadenopathy, pregnancy, trauma, viral infection, and hyperglycemia in a diabetic.^[4-8] This laparoscopic image demonstrates endometriosis with adhesions (arrow).

Intussusceptions may be transient in nature and may have episodic symptoms, as is seen in this case and in most pediatric patients. If persistent, however, intussusception can lead to bowel obstruction. The entrapped blood vessels may become occluded, leading to edema and worsening entrapment (shown). Unfortunately, most adults present with nonspecific abdominal complaints and without palpable masses; additionally, fewer than 30% have guaiac-positive stools (although the classic presentation includes currant red-jelly stools).^[9-11] Failure to diagnose a fixed intussusception can lead to subsequent bowel ischemia, sepsis, and ultimately death.

The diagnosis of adult intussusception requires a high index of suspicion given the vague and often transient findings. Plain abdominal radiographs are typically the first investigation ordered in patients. The classic findings on plain radiography are the presence of a large soft-tissue density from the intussusception, as in this pediatric patient (circle). Secondary findings, such as air-fluid levels, proximal bowel dilation, and collapsed distal bowel are more likely. Image courtesy of Radiopaedia.

Is the following statement TRUE or FALSE?: Endoscopy is the modality of choice for the diagnosis of intussusception in adults.

Answer: False. Endoscopy is contraindicated for intussusception in adults.

Abdominal ultrasonography and barium studies are not useful modalities for evaluating adult patients. Endoscopic examination has been used in rare cases, either intentionally or incidentally, as seen in this image from a case of an ileocolonic intussusception showing ulcerative lesions.^[12-14] Attempts at endoscopic reduction in adults are not recommended. Barium enema reduction is not indicated for patients who have had symptoms for more than 3 days because the risk of perforation is high. Contrast-enhanced abdominal CT is the most accurate modality for the detection of intussusception and the associated potential complications.

Given the vague nature of many adult intussusception presentations, the list of differential diagnoses will be tailored to the specific presenting complaints. For patients with vague symptoms of abdominal pain, diarrhea or constipation, and weight loss, the list of differential diagnoses is extremely broad and includes malignancy, chronic mesenteric ischemia, endometriosis, irritable bowel syndrome, chronic pancreatitis, dyspepsia, and infection. A gross pathology sample from a right hemicolectomy seen here demonstrates a large colorectal neoplasm.

Among the differential diagnoses, appendicitis may be considered. In appendicitis, the classic history of anorexia and periumbilical pain followed by nausea, right lower quadrant pain, and vomiting occurs in only 50% of cases; it may mimic several abdominal conditions, which may make establishing this diagnosis a clinical challenge. The previously mentioned barium-enhanced radiographic examination shows a normal, completely contrast material-filled appendix (arrows), which effectively excludes the diagnosis of appendicitis.

Chronic pancreatitis is also part of the differential diagnosis. Patients typically present with intermittent attacks of severe pain, often in the mid or left upper abdomen and occasionally radiating to the back; they are often symptomatic for years before the diagnosis is established. This plain abdominal radiograph shows coarse calcifications in the distribution of the pancreas due to chronic calcific pancreatitis.

For patients who have progressed to the point of obstruction and early ischemia, the vital signs, laboratory values, and clinical examination should help narrow the differential diagnosis. Emergent conditions that need to be excluded include mesenteric ischemia, ruptured aneurysm, obstruction, pancreatitis, abscess, renal stones, diverticulitis, biliary disease, and volvulus. CT should facilitate differentiation among these disease processes. This CT scan shows acute pancreatitis with pancreatic necrosis (red arrow).

The patient's clinical condition remains stable. After identification of the colocolonic intussusception, the patient is admitted to the hospital for further treatment.

What is the treatment of choice for the colocolonic intussusception in this patient?
A. Close monitoring and frequent re-evaluation
B. Nonoperative reduction with monitoring and frequent re-evaluation
C. Nonoperative reduction with subsequent surgical excision
D. Surgical excision without reduction

Answer: D. Surgical excision without reduction

Unlike pediatric patients, surgical management is the treatment of choice for intussusception in adults. Whether diagnosed preoperatively or discovered at the time of an emergency laparotomy, the involved bowel must be resected. Currently, most of these surgeries are open procedures, but in the future, laparoscopic procedures may be performed more often when the diagnosis is known preoperatively. This laparoscopic image shows a jejuno-jejunal intussusception repair.

Bowel resection without prior reduction is the management of choice for colocolonic intussusception because of the high risk of malignancy and the concern for malignant seeding. Reduction should also be avoided in cases with an ischemic or inflamed bowel. The risk that mucosal necrosis may extend beyond the resection margins is increased following reduction.^[15,16] However, reduction in other settings is controversial. An intraoperative image of an ileoileal intussusception is shown.

Following admission, the patient was brought to the operating room, wherein the surgical team elected to perform a colonoscopy. This revealed a large mass completely obstructing the lumen of the transverse colon. The involved bowel was resected. Pathology identified an adenocarcinoma in the transverse colon (shown), which was the likely lead point. Postoperatively, the patient fared well, and she was discharged to home on hospital day 6. Image courtesy of Wikimedia Commons.

More Slideshows

• Abdominal Vascular Occlusion
• An Atypical and Potentially Deadly Abdominal Emergency: Case Quiz
• Can't Miss Intestinal Complications on Abdominal Radiographs
• Case Quiz: A Can't-Miss Abdominal Catastrophe
• Case Quiz: A Deadly Cause of Vomiting in a Newborn
• Critical Findings on Plain Abdominal Radiographs

For More Information

• Medscape Reference: Imaging in Child Intussusception
• Medscape Reference: Intussusception
• Medscape Reference: Pediatric Intussusception Surgery

Contributor Information

Authors
Derik L Davis, MD
Resident Radiologist Affiliated with Albert Einstein College of Medicine Department of Radiology
Bronx Lebanon Hospital Center
Bronx, New York
Disclosure: Derik L. Davis, MD, has disclosed no relevant financial relationships.

Harvey Stern, MD
Staff Radiologist
Chairman of Radiology Affiliated with Albert Einstein College of Medicine Department of Radiology
Bronx Lebanon Hospital Center
Bronx, New York
Disclosure: Harvey Stern, MD, has disclosed no relevant financial relationships.

Helen T Morehouse, MD
Staff Radiologist
Professor of Radiology Affiliated with Albert Einstein College of Medicine Department of Radiology
Bronx Lebanon Hospital Center
Bronx, New York
Disclosure: Helen T. Morehouse, MD, has disclosed no relevant financial relationships.

Editors
Matthew Tichauer, MD
Resident Physician
Department of Emergency Medicine
UMDNJ-Robert Wood Johnson Medical School
New Brunswick, New Jersey
Disclosure: Matthew Tichauer, MD, has disclosed no relevant financial relationships.

Raffi Kapitanyan, MD
Assistant Professor
Department of Emergency Medicine
UMDNJ-Robert Wood Johnson Medical School
New Brunswick, New Jersey
Disclosure: Raffi Kapitanyan, MD, has disclosed no relevant financial relationships.

Catherine A. Lynch, MD
Assistant Professor
Department of Surgery, Division of Emergency Medicine
Duke University Medical Center
Faculty, Duke Global Health Institute
Durham, North Carolina
Disclosure: Catherine A. Lynch, MD, has disclosed no relevant financial relationships.

Editors
Carmen Cuffari, MD
Associate Professor
Department of Pediatrics, Division of Gastroenterology/Nutrition
Johns Hopkins University School of Medicine
Baltimore, Maryland
Disclosure: Carmen Cuffari, MD, has disclosed no relevant financial relationships.

Andréa B. Lese, MD, MA
Co-Director of Clinical Review, Medscape Reference Case Presentations
Resident, Department of Orthopedic Surgery and Rehabilitation
Yale School of Medicine
Yale-New Haven Hospital, New Haven, Connecticut
Disclosure: Andréa B. Lese, MD, MA, has disclosed no relevant financial relationships.