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January 14, 2019

Image challenge: A rare case of colonic intussusception in an adult

What caused an adult patient with numerous polypoid lesions in the gastric body and duodenum, but not in the esophagusa, and a large cecal polyp, intussusception?

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Gastroenterology clinical image challenge: A 60-year-old Japanese woman visited the emergency department with sudden onset of abdominal pain and several weeks of progressively worsening diarrhea, vomiting and weight loss. She had no relevant family history. 

Physical examination revealed whole abdominal tenderness along with atrophy of the fingernails and skin pigmentation (figure). Laboratory tests revealed hemoglobin 5.7 g/dL, albumin 1.9 g/dL, potassium 1.9 mmol/L. and C-reactive protein 92 mg/L. Serum carcinoembryonic antigen and carbohydrate antigen 19-9 were 5 ng/mL (upper limit of normal, 5) and 12 IU/mL (upper limit of normal, 37), respectively. 

A contrast-enhanced computed tomography scan of the abdomen revealed concentric circles with no ischemic changes from the ascending to the transverse colon and a luminal mass (figure). We performed a contrast enema under the supervision of surgeons. We detected a huge lead-point mass on the transverse colon and an intussusception that could be reduced by retrograde pressure from the enema (figure). The patient’s condition improved after reduction of the intussusception, and she underwent an esophagogastroduodenoscopy that revealed numerous polypoid lesions in the gastric body and duodenum, but not in the esophagus (figure). Colonoscopy revealed a large cecal polyp that was considered as the lead-point of the intussusception (figure). Several small polyps were also found predominantly in the right side of the colon.

Based on the clinical scenario and images, what is the most likely underlying disease responsible for the patient’s intussusception? 

To find out the diagnosis, read the full case in Gastroenterology or download our Clinical Image Challenge app through AGA App Central, which features new cases each week. Sort and filter by organ, most popular or favorites. AGA App Central is available in both the Apple App Store and Google Play.

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