Adult intussusception is a rare condition and can be divondary to an intestinal lipoma. In this case report, a 41-year-old woman presented with an acute abdominal pain and a tender central abdominal mass. Abdominal computed tomography scan showed an ileo-ileal intussusception with a fat-density mass at the leading point. Laparotomy with reduction of the intussusception, bowel redivtion and anastomosis was performed. Histological examination revealed a benign submucosal lipoma.
Early laparotomy with redivtion and without deintussusception is usually recommended. In this case, a careful reduction allowed to preserve the non necrotic intestinal segment involved in the intussusception.
Case Report
A 41-year-old woman presented with an acute central abdominal pain associated with vomiting, 24 hours prior to admission. She had no fever, no blood in stools nor changes in bowel habits. No previous similar episode was reported.
Abdominal examination revealed a central tender sausage-shaped mass with no other significant physical findings. Blood tests were normal, except white blood cell count of 13500/mL. Abdominal CT scan showed a segment of ileo-ileal intussusception. Moreover, a rounded well-limited low-density lesion was identified as the lead point causing the intussusception [Table/Fig-1,2]. There were no signs of obstruction and no other lesions were found.
Abdominal computed tomography scan showing a rounded fatty mass in the small intestine.
Abdominal computed tomography scan. Coronal view showing the “sausage” shape of the intussusception.
The patient was diagnosed preoperatively as having an ileo-ileal intussusception caused by a lipoma in the small intestine, relying on the CT scan findings that showed the low density lesion with lipid attenuation. Laparotomy confirmed the presence of enteroenteric intussusception involving the proximal Ileum [Table/Fig-3]. A manual reduction was gently performed. The length of the intussuscepted ileal segment was 120 cm in which 50 cm were necrotic [Table/Fig-4]. The leading point was a palpable endoluminal rounded mass which was resected with the necrotic bowel, 70 cm in total. Primary anastomosis was performed. The tumour appeared macroscopically as fatty tissue [Table/Fig-5]. Pathological examination revealed a benign submucosal lipoma. Postoperative course was uneventful and the patient was discharged on the 6th postoperative day.
Discussion
Adult intestinal intussusception is a rare clinical entity. Usually the underlying cause is a malignant or a benign tumour [1,2]. Intestinal lipoma has been reported among the benign causes. It accounts for 2% of all gastro-intestinal tumours. It can act as the leading point of the intussusception due to its intraluminal location [3]. Intestinal lipomas were found in the ileum in 22 cases among the 51 cases as reported by Mouaqit O et al., [3]. About 23 more cases of intestinal intussusceptions caused by lipomas, in the English literature was compiled since August 2012. Lipomas were located in the ileum in nine cases [Table/Fig-6] [3-25]. The clinical presentation is non-specific and the typical clinical triad of abdominal pain, a sausage-shaped mass and red jelly stools, usually lacks in adults making this condition difficult to diagnose [26].
Intraoperative findings: Ileoileal intussusception with signs of ischemia.
Intraoperative findings: After partial reduction. Intussuscepted segment with both necrotic and viable bowel.
Intraoperative findings: Submucosal rounded fatty mass.
Case reports of intestinal intussusceptions caused by lipomas reported in the English literature since August 2012 [3-25].
| Gender | Age | DG | Location | Size (cm) | Treatment | Author | Year |
|---|
| Male | 55 | CT | Colon | 3 | Right hemicolectomy | Mouaqit O et al., [3] | 2013 |
| Female | 52 | CT* | Ileum | 6 | Ileal resection | Uyulmaz S et al., [4] | 2018 |
| Male | 22 | CT | Ileum | - | Ileal resection | Vagholkar K et al., [5] | 2015 |
| Male | 50 | CT | Ileum | 4 | Ileal resection | Jiang RD et al., [6] | 2015 |
| Female | 45 | CT | Ileum | - | Ileal resection | Fazeli MS et al., [7] | 2014 |
| Female | 52 | CT, Colonoscopy | Ileum | 0,3-5 | Ileal resection | Gao PJ et al., [8] | 2014 |
| Female | 30 | US | Ileum | 3 | Ileocaecal resection | Bosman WM et al., [9] | 2014 |
| Female | 30 | CT | Ileum | - | Right hemicolectomy | Molnar C et al., [10] | 2013 |
| Female | 73 | CT, Colonoscopy | Ileum | 3 | Endoscopic | Lee ES et al., [11] | 2013 |
| Male | 55 | Laparotomy | Ileum | 4 | Ileal resection | Singhal S et al., [12] | 2012 |
| Male | 40 | CT, Colonoscopy | Colon | 6 | Segmental colectomy | M’rabet S et al., [13] | 2018 |
| Female | 65 | Laparotomy | Colon | 9 | Left hemicolectomy | Ongom PA et al., [14] | 2012 |
| Female | 44 | CT | Jejunum | 3 | Jejunal resection | Seow-En I et al., [15] | 2014 |
| Male | 47 | CT | Ileocaecal valve | 3 | Ileo-caecal resection | Kumar K et al., [16] | 2017 |
| Female | 47 | CT | Colon | 9 | Right hemicolectomy | Casiraghi T et al., [17] | 2016 |
| Male | 50 | CT, Sigmoidoscopy | Colon | 6 | Left hemicolectomy | Low HM et al., [18] | 2016 |
| Male | 57 | CT, Colonoscopy | Colon | 6 | Segmental colectomy | De Figueiredo LO et al., [19] | 2016 |
| Female | 52 | US*, CT | Ileocaecal valve | 5 | Right hemicolectomy | Stancu B et al., [20] | 2016 |
| Male | 44 | CT | Colon | 6 | Right hemicolectomy | Arslan E et al., [21] | 2017 |
| Female | 73 | US, CT | Ileocaecal valve | 6 | Right hemicolectomy | Gys B et al., [22] | 2015 |
| Female | 65 | CT, Colonoscopy | Ileocaecal valve | 7 | | Kang B et al., [23] | 2014 |
| Male | 56 | CT | Colon | - | Right hemicolectomy | Eyselbergs M et al., [24] | 2014 |
| Female | 54 | CT | Colon | 6 | Left hemicolectomy | Grasso E et al., [25] | 2012 |
*CT: Computed tomography, *US: Ultrasonography
The best diagnostic modality is abdominal CT scan [27]. The finding of lipid attenuation (-100 to -50 HU) is mandatory to the diagnosis of a lipoma [28,29]. To avoid mistaking the lipoma for intraluminal gas or invaginated mesenteric fat, the observation of the images reformatted in multiple dimensions, with the optimal window and oral contrast filling of the bowel can be needed [30]. Possible vascular compromise is difficult to assess on axial images with conventional CT scan. A much better assessment of the vascular supply to the affected bowel loop and of the intussusception length can be made using multidetector CT [31]. In our patient preoperative diagnosis was made successfully supported by CT scan findings. Other modalities include colonoscopy which allows a direct visualisation of the lipoma and it is more appropriate to assess colonic localisation [13]. Nevertheless, colonoscopy was useful for the diagnosis for ileal lipoma with ileo-colic intussusception in two case [8,31]. The other diagnostic tools reported are ultra-sonography, barium studies and video capsule endoscopy [3]. Intraoperative diagnosis during exploratory laparotomy were reported in two cases [12,14].
Laparotomy with bowel resection and primary anastomosis is the treatment of choice. In colonic intussusceptions, it is recommended to perform resection in block without reduction. For entero-enteric cases, a selective approach can be applied. Reduction is not recommended when signs of bowel ischemia or inflammation are present or malignancy is suspected [15,28]. Intraoperative reduction of the instussusception prior to resection may preserve a considerable length of bowel [4,5]. In this case, the preoperative diagnosis of ileal lipoma being made, the involved bowel segment was long and even though the bowel showed signs of ischemia, we attempted reduction successfully, which allowed us to spare 50 cm of bowel length. This method could have caused inadvertent bowel injury that is why it should be performed gently. Reduction should be abandoned and followed by resection anastomosis if the attempt is not harmless and successful [32].
Conclusion
Submucosal intestinal lipoma can cause intussusception presenting as an acute tender abdominal mass. The preoperative diagnosis is possible with CT scan; showing a target sign or a pseudo kidney sign with a fat-density lead point. Early surgery allows definitive diagnosis and treatment which is resection with primary anastomosis.
*CT: Computed tomography, *US: Ultrasonography
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