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Diagnosis of Symptomatic Intestinal Metastases Using Transabdominal Sonography and Sonographically Guided Puncture

Hans Peter Ledermann1, Christoph Binkert2, Eckhart Fröhlich3, Norbert Börner4, Christoph Zollikofer5 and Gerd Stuckmann5

1 Department of Radiology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland.
2 Department of Radiology, University Hospital Balgrist, Forchstr. 340, 8008 Zürich, Switzerland.
3 Department of Internal Medicine, Karl Olga Krankenhaus, Schwarenbergstr. 7, 70190 Stuttgart, Germany.
4 Praxis Innere Medizin und Gastroenterologie, Parcusstr. 8, 55116 Mainz, Germany.
5 Department of Radiology, Kantonsspital Winterthur, Brauerstr. 15, 8400 Winterthur, Switzerland.



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  		Fig. 1. —Sonographically guided 18-gauge core biopsy in 53-year-old woman with metastasis to ascending colon from gastric cancer. Transverse sonogram of ascending colon shows diffusely thickened wall. Note optimal placement of 18-gauge core biopsy device with tangential approach to bowel without violation of hyperechoic narrowed lumen (open arrow). Trajectory of needle is indicated with dashed line. Tip of needle is marked with solid white arrow.

 


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  		Fig. 2A. —57-year-old man with metastatic malignant melanoma who presented with acute peritonitis. Transverse sonogram of ileal metastasis shows marked hypoechoic thickening of bowel wall (as much as 1.5 cm in diameter) and loss of normal stratification. Note slitlike luminal narrowing with hyperechoic gas and adjacent lymph node between crosses.

 


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  		Fig. 2B. —57-year-old man with metastatic malignant melanoma who presented with acute peritonitis. Pathologic specimen after resection confirms marked segmental bowel wall thickening with narrowing of lumen.

 


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  		Fig. 3A. —61-year-old woman with bronchial carcinoma who presented with nonspecific intermittent right lower quadrant pain due to sonographically diagnosed ileal metastasis. Transverse sonogram of terminal ileum shows excessive segmental hypoechoic bowel wall thickening as much as 1.8 cm in diameter with loss of stratification and peristalsis.

 


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  		Fig. 3B. —61-year-old woman with bronchial carcinoma who presented with nonspecific intermittent right lower quadrant pain due to sonographically diagnosed ileal metastasis. CT scan confirms concentric thickening of terminal ileum.

 


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  		Fig. 4A. —70-year-old man with metastatic malignant melanoma who presented with intermittent crampy abdominal pain. Transverse sonogram of right lower abdomen shows ileoileal intussusception seen as "ring in ring sign." Outer hypoechoic ring is formed by intussuscipiens (invaginating ileum). Inner hypoechoic round area is formed by intussusceptum (entering limb of invaginated ileum) with mucosal melanoma metastasis in center. Hyperechoic crescent between two rings is formed by invaginated mesenteric fat.

 


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  		Fig. 4B. —70-year-old man with metastatic malignant melanoma who presented with intermittent crampy abdominal pain. Transverse sonogram at apex of intussusception shows invaginated hypoechoic irregularly bordered melanoma metastasis in ileal lumen.

 


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  		Fig. 4C. —70-year-old man with metastatic malignant melanoma who presented with intermittent crampy abdominal pain. Doppler sonogram of intraluminal mucosal metastasis reveals strong capillary blood flow.

 


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  		Fig. 4D. —70-year-old man with metastatic malignant melanoma who presented with intermittent crampy abdominal pain. CT scan shows ileum with contrast material in its lumen being invaginated by mesenterically thickened ileum segment.

 

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