IMPORTANT: We currently have a number of bugs related to image cropping and are actively trying to resolve them. In the meantime, we have disabled cropping. Apologies for any inconvenience. Stay informed: radiopaedia.org/chat

Descending colon tumor causing intussusception

Case contributed by Wayland Wang
Diagnosis certain

Presentation

Abdominal distension. Vomiting. Anemic. Hypotensive.

Patient Data

Age: 70
Gender: Female

IDC and right femoral venous + arterial lines in situ. There is intraperitoneal free gas and free fluid, mainly around the liver and in the left paracolic gutter. In the mid descending colon there is a large intussuscepting colonic tumor without associated obstruction. Fluid in the left paracolic gutter raises the suspicion of a descending colon perforation. In the pelvis a there are several large collections.

The jejunum and proximal ileum are thick walled, although the bowel wall enhancement is preserved. There is gas and fluid in the mesentery and surrounding the small bowel. The mesenteric vessels appear intact but there is a (probable) incidental partial small bowel malrotation. There are no grossly dilated loops of bowel.

Incidentally noted gallstones without CT evidence of complication. Small area of hypodensity in segment 4B of the liver adjacent to the falciform ligament is likely an area of focal fatty infiltration or perfusion phenomenon. Focus of splenic calcification noted. The right kidney is atrophic. Bilateral hypodense renal lesions up to 1 cm have the characteristics of simple cysts. Pancreas, adrenals, stomach and duodenum are unremarkable.

T12 superior endplate compression fracture is old. Mild bibasal dependent atelectasis.

Conclusion:

Large descending colon tumor partly intususcepting into adjacent colon, which is likely perforated. There is peritonitis with multiple discrete collections.

CLINICAL NOTES:

1) Descending colon - perforation, ?Ca

2) Spleen Laparotomy for perforated large bowel.

MACROSCOPIC DESCRIPTION:

1. "Bowel": Colon, 180mm. No peritoneal reflection present, with up to 80mm attached mesocolon. There is an ulcerated polypoid mucosal tumor, 80x80x50mm, located 70mm from the distal longitudinal margin and well clear of the mesenteric margin. The tumor centrally extensively invades muscularis propria and subserosa. At the periphery of the tumor is a transmural defect, however invasion is not definitely identified at this point. The serosa is unremarkable (inked blue). The serosa of attached appendix epiploica is focally covered with a light cream exudate. Lymph nodes up to 6mm are identified.

BLOCK DESIGNATION: A - margins, LS (blue proximal, green distal). B-E - tumor (B and C rupture, D central, E with normal bowel). F&G - lymph nodes. P7.

2. "Spleen": Intact spleen, 95x70x40mm, 139g. The surface is coated with a patchy cream exudate. No lymph nodes identified. No focal lesions seen.

BLOCK DESIGNATION: A&B - 2x representative LS. 

MICROSCOPIC DESCRIPTION:

1. Sections show a tumor arising in an ulcerated high grade colonic tubular adenoma. The tumor is composed of large irregular glands containing necrotic debris in a desmoplastic stroma. Tumor cells are columnar with large pleomorphic nuclei and prominent nucleoli. Tumor extensively invades the subserosa. Lymphovascular and perineural invasion are not seen. There is a large peritumoral abscess that perforates the large bowel. There is an acute serositis on the adjacent bowel but no tumor is seen on the serosa. No metastatic tumor is seen in 11 mesenteric lymph nodes. Cytoplasmic yellow/brown pigment is present in the histiocytes within some nodes. The margins are clear.

2. Sections of the spleen show preserved red pulp and white pulp architecture. There is an acute perisplenitis. There is no evidence of malignancy.

DIAGNOSIS:

1. Descending colon segmental resection: Moderately differentiated adenocarcinoma. Size - 80mm. Invasion - extensive subserosal invasion; serosa clear; no lymphovascular invasion Margins - clear. Lymph nodes - no tumor in 11 mesenteric lymph nodes. Other - tumor-associated perforating peritumoral abscess.

2. Splenectomy: Acute perisplenitis; no evidence of malignancy.

AJCC stage (7th edition) IIA (pT3 N0).

Case Discussion

This case illustrates several complications of intestinal neoplasm.

Intussusception is a frequent complication of mobile bowel, typically small bowel. In the colon intussusception can still occur, however is often not as extensive as in the small bowel due to the relative lack of mobility of colon. Whenever long segment small bowel or any large bowel intussusception is detected, one must look carefully at the lead point to find a cause.

Perforation can be preceded by bowel obstruction due to the tumor, or be a result of direct tumor invasion through the bowel wall. This case shows free perforation, but often in cases of direct tumor invasion the perforation can be subtle, and result in fistulation into adjacent organs.

How to use cases

You can use Radiopaedia cases in a variety of ways to help you learn and teach.

Creating your own cases is easy.

Updating… Please wait.

 Unable to process the form. Check for errors and try again.

 Thank you for updating your details.