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A 58 year old man with epigastric pain and mass

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c1908 (Published 21 April 2010) Cite this as: BMJ 2010;340:c1908
  1. Shouvik Saha, specialist registrar in radiology1,
  2. Naren Basu, specialist registrar in general surgery2,
  3. David Howlett, consultant radiologist1
  1. 1Department of Radiology, Eastbourne District General Hospital, Eastbourne BN21 2UD
  2. 2Department of Surgery, Eastbourne District General Hospital
  1. Correspondence to: S Saha shouvik.saha{at}doctors.org.uk

    A 58 year old man was referred by his general practitioner to the surgical assessment unit with severe colicky epigastric pain. He had been experiencing intermittent abdominal pain for five months. In the days leading up to admission his pain worsened and was barely controlled on admission with intravenous morphine. He reported bouts of diarrhoea alternating with constipation, a loss of appetite, and weight loss during the past six months. He had not vomited and had opened his bowels the day before admission. He had no other history of note. On examination he was thin and frail. His pulse rate was 110 beats/min, blood pressure was 150/90 mm Hg, and oxygen saturations were 98% using pulse oximetry. His abdomen was mildly distended. A non-expansile, mildly tender epigastric mass was noted on palpation. Bowel sounds were normal. Rectal examination showed an empty rectum. Blood tests showed mild normocytic anaemia with haemoglobin 113 g/l, white cell count 16.1×109/l, and C reactive protein 90 mg/l. Chest radiography was unremarkable but the abdominal radiograph suggested an epigastric mass. He underwent computed tomography of the abdomen for further assessment (fig 1).

    Fig 1 Axial computed tomogram at the level of the transverse colon


    • 1 What does the computed tomogram show?

    • 2 What underlying causes would you consider?

    • 3 How should the patient be managed?


    1 What does the computed tomogram show?

    Short answer

    The computed tomogram shows an intussusception of the ascending colon (intussusceptum) into the transverse colon (intussuscipiens) (fig 2).

    Fig 2 Ascending colon mass at the lead point of intussuceptum (long arrow). Characteristic mesenteric fat is seen between the intussusceptum (arrowheads) and the transverse colonic intussuscipiens (short arrows)

    Long answer

    Intussusception can be confidently diagnosed on computed tomography in adults because of its almost pathognomonic appearance.1 It appears as a soft tissue attenuation mass, consisting of the …

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