Presentation
Three days of abdominal pain, nausea, vomiting and constipation. Background history of melanoma.
Patient Data
Chest: multiple nodular opacities projected on both hemithorax predominantly in the lower third of the right lung. Pleural effusion is not observed.
Abdomen: dilatation of the small intestine with air-fluid levels consistent with small bowel obstruction. Cholelithiasis.
Distal ileo-ileal intussusception that causes retrograde dilatation of the small intestine up to 3.8 cm and dilatation of the stomach. A nodular lesion with enhancement in the contrast phase is present in the distal ileum adjacent to the region of intussusception, measuring 1.9 cm in its longest axis.
Diverticula in the colon without associated inflammatory changes.
Mild splenomegaly.
Indeterminate nodules (at least two) in the left adrenal gland of 13.2 mm and 12.5 mm that show peripheral enhancement after contrast medium administration.
Lymph node enlargement in the right common iliac, right internal iliac, right external iliac and bilateral inguinal chains.
There is no free intra-abdominal fluid or gas.
In the included lung bases, multiple solid nodules representing secondary deposits.
The operative findings were as follows:
1. Dominant ileo-ileal intussusception not reducible at 200 cm from the angle of Treitz, approximately 10.0 cm, secondary to metastatic lesions of at least 5.0 cm.
2. Dilated loops of the small intestine and gastric chamber with evident change in caliber after 1.
3. At least four additional dark metastatic lesions in the ileum distributed between 200 cm to 300 cm from the ligament of Treitz, one of them with reducible intussusception.
The pathology report: resection of the ileum.
1. Multiple metastases due to malignant melanoma, the largest up to 3.6 cm.
2. Negative resection margins
3. Intestinal wall with mild edema of the mucosa without other notable histological alterations.
Case Discussion
One of the most frequently reported sites of metastatic disease in cutaneous melanoma is gastrointestinal 1,2.
Secondary deposits at this level by themselves may not cause symptoms in most cases but alter the normal peristalsis of the affected site, leading to complications 3.
Intussusception is an unusual complication associated with metastatic melanoma lesions in the gastrointestinal tract 2. It presents with abdominal pain, vomiting and in more severe cases the passage of feces with characteristics of currant jelly.
The target sign in the axial plane and the morphology pattern of the intestine within the intestine in the sagittal plane are characteristic signs on abdominal CT 3.
The treatment of the complication is surgical with resection of the affected segment when it is symptomatic 3.
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