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Case of the Month

by Dr K C Choy AM (Mal), MBBS, M.Med, FRCR

Answer to Case Of the Month 

Discussion of Findings
CT scan showed a bowel related mass in the right side of the abdomen. The lower section showed a typical “target” or “doughnut” sign due to multiple layers of bowel wall and intestinal fluid contents.  

US (not shown) is the preferred imaging modality in assessment of an abdominal mass in a child. Typically, a doughnut or pseudokidney sign is seen.  

The barium enema showed non-filling of the hepatic flexure and ascending colon with streaks of barium flowing in between the layers of bowel giving a “coil spring” appearance. 

Findings at operation 
At laparotomy, a caecal tumour was found and HPE showed Burkitt’s lymphoma of the caecum.

Non African Burkitt’s lymphoma most frequently involves the gastrointestinal tract and usually presents as an abdominal mass.

  

Intussusception
Intussusception is the invagination of bowel, the intusscipiens by another loop of bowel, the intussusceptum. Four varieties are described, that is, ileocolic, colocolic, ileoilealcolic and ileoileal.
 
This condition typically occurs in infants between 6 months to 2 years. In the idiopathic group, usually no lead point is identified. It is thought that hypertrophy of the Peyer’s patches possibly due to viral infection may be a triggering factor. Pathological intussusception occurs due to a known lead point such as Meckel’s diverticulum, intestinal duplication and polyps. Thickened edematous bowel in Henoch Schonlein purpura and haemolytic uraemic syndrome as well as bowel tumour in lymphoma and Burkitt’s lymphoma may also cause intussusception. Intestinal polyps in Peutz Jegher’s syndrome is also a known cause.

Non operative reduction of intussusception is attempted in infants when no lead point is suspected. Hydrostatic or pneumatic reduction under flouroscopy or ultrasound may be attempted.
 
In older children such as in this patient, there is usually a pathological lead point and surgical reduction is preferred to enable positive identification for the cause of the intussception.
 
About the Author 
Dr K C Choy is currently attached to the Mahkota Medical Centre, Melaka as Radiologist.

 

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Thursday, 21 August, 2003