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| CASE REPORT |
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| Ahead of print publication |
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Intestinal lipoma causing intussusception in an adult – A case report
Vaishali Pol1, Sayali Deshmukh2, Anand Bhosale2, Jaydeep Pol1, Vivek Dugad2
1 Department of Surgical Pathology, Deep Pathology Laboratory, Miraj, Maharashtra, India
2 Department of Pathology, Symbiosis Medical College for women and Symbiosis University Hospital and Research centre, Symbiosis International (Deemed University), Lavale Pune, Maharashtra, India
| Date of Submission | 02-Nov-2022 |
| Date of Decision | 14-Dec-2022 |
| Date of Acceptance | 17-Dec-2022 |
| Date of Web Publication | 14-Mar-2023 |
Correspondence Address:
Sayali Deshmukh,
D1802, 24K Sereno, Pancard Club Road, Baner, Pune - 411 045, Maharashtra
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/mjdrdypu.mjdrdypu_929_22
Intussusception is a pediatric condition that is rare in adults. It is usually associated with lead points affecting the intestine. Lipomas are very rare benign tumors which may act as lead points for intestinal intussusception. Indeed, the incidence of intestinal intussusception caused by lipomas is very rare. Our patient is a 38-year-old female, previously healthy and admitted for colicky right lower quadrant abdominal pain of 2-day duration. Computed tomography (CT) scan of the abdomen and pelvis showed a prominent "target sign" in the right lower abdomen which was suggestive of long segment ileocolic intussusception. Urgent laparotomy opted for ileocolic intussusception and right hemicolectomy with end-to-side isoperistaltic ileocolic anastomosis was performed. The pathology report showed that intussusception was induced by a colon lipoma. Thus, ileocolic intussusception caused by lipoma should be considered in the differential when diagnosing adults with right lower quadrant pain.
Keywords: Abdominal pain, intussusception, lipoma, pediatric condition
How to cite this URL:
Pol V, Deshmukh S, Bhosale A, Pol J, Dugad V. Intestinal lipoma causing intussusception in an adult – A case report. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2023 Mar 24]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=371652 |
| Introduction | |  |
Intussusception was first described in 1964 by Barbette of Amsterdam. It is defined as telescoping of one segment of the bowel into another.[1] Intussusception is a pediatric condition that occurs rarely in adults with an overall incidence of 2-3 cases per 1,000,000 of the general population per year.[2] 1 in 1300 of abdominal cases presenting as obstruction reveals intussusception after performing investigations.[3] Lipomas are benign, slow-growing tumors of mesenchymal cells. They arise from either submucosal adipose tissue or serosal fat and have varied clinical presentations or may present as an incidental finding.[4] Usually, they present as solitary lesions but multiple lipomas can be seen in <5% of cases.[5] A lead point is found in 70–90% of adult intussusceptions whereas 90% of pediatric intussusceptions are idiopathic.[6] Pathological lesions like carcinoma, lymphoma, lipomas, and polyp in the intestinal lumen can act as a lead point to produce intussusception. Lipomas are the lead points in nearly 17% of intestinal intussusceptions.[5] In this article, we present a case of 38-year-old-female with ileocolic intussusception secondary to lipoma.
| Case Report | | |
A 38-year-old woman presented with complaints of colicky pain in right lower abdomen, associated with abdominal distension and vomiting for two days. The patient denied any complaints of nausea, vomiting, fever, chills, or change in bowel habits. All vitals were within normal range. Her abdomen was distended with generalized tenderness and diffuse guarding. The bowel sounds were exaggerated. Clinical diagnosis of intestinal obstruction was made. Differential diagnoses of ileocecal tuberculosis, colitis, and inflammatory bowel disease were made. Laboratory investigations were insignificant except for raised white cell count of 20 × 109/L with neutrophils 89% and CRP of 260 mg/L. CT abdomen and pelvis showed a prominent "target sign" in the right lower abdomen, suggestive of ileocolic intussusception. Exploratory laparotomy was done. During exploration, the affected bowels (intussusceptum and intussuscipien) were identified along with an intestinal mass. Right ileocolonic resection was done. We received a gross specimen of ileocolonic resection with intussusception measuring 10 × 3 × 2 cm. The ileum showed a polypoidal mass with resultant intussusception measuring 2 × 1 × 1 cm.
Cut section revealed a protruding mass arising from the intestinal wall measuring 2 × 1 × 1 cm which had a yellow, soft homogeneous cut surface. [Figure 1.1], [Figure 1.2]. Microscopic examination showed a mass arising from the ileal wall on the serosal aspect. In areas, the overlying mucosa was ulcerated and the muscle coat was of variable thickness, in areas thinned out significantly. The mass showed lobules of mature adipocytes with delicate vasculature in the fibrovascular septae. No nuclear atypia was noted. Changes of gangrene were not seen. [Figure 2.1]. The patient stayed in the hospital for one week and the postoperative course was uneventful.
| Discussion | | |
Intussusception is defined as telescoping of one segment of bowel into another.[1] Intussusception is a common pediatric condition and occurs relatively rarely in adults.[2] Intussusceptions are classified based on their location. They are commonly classified into four categories: ileoileal, ileocolic, ileocecal, and colocolic. About 15% of all intussusceptions are ileocolic characterized by prolapse of the terminal ileum through the ileocecal valve into the colon.[7] Intussusception commonly affects young children up to 4 years. Intussusception in adults is seen in only 5%–10% of all reported cases.[8] The classical triad of abdominal pain, palpable mass, and red currant jelly-like stools is rare in adults, which often leads to misdiagnosis. Also, the identifiable lesion, which acts as the lead point, is generally a malignant tumor. Intussusception most commonly occurs in the age group of 40 to 70 years; however, it may also affect young patients. Women (57%) are more frequently affected than men (43%).[9]
Lipomas are found anywhere along the gastrointestinal tract, the most common location being the terminal ileum.[3] Lipomas are slow-growing tumors with no clinical signs or symptoms. Lesions <1 cm are usually asymptomatic, while those >4 cm in size is more likely to cause symptoms. Symptoms such as abdominal pain, diarrhea, constipation, and bleeding tend to occur when the lesion is >2 cm in size.[10] Lipomas of the bowel are usually submucosal, intermuscular and subserosal are less common.[3]
The radiologic modalities that aid in diagnosing intussusception are plain abdominal X-ray, ultrasonography, and CT scan. Abdominal X-ray is the first diagnostic tool used. It can be negative in the early stages, or it can highlight the presence of air-fluid levels, the absence of air in the upper and lower right quadrants, with increased soft tissue density, or show a "crescent" sign that is typical of intussusception, caused by the trapping of gas between the two mucous surfaces of the invaginated bowel.[7] However, X-ray has low sensitivity and specificity.[10] Abdominal ultrasound can detect intussusception as a "target sign," "pseudo kidney sign," or "crescent in a doughnut sign". However, the findings can be obscured by bowel gas in cases of obstruction.[10] CT scan is the most commonly used investigative modality for the acute abdomen. It has a sensitivity of 71-87% and a specificity of up to 100%.[10] CT scan shows a "target sign" or a "sign of doughnut".[7] Endoscopically, submucosal lipoma appears as a mass covered by normal mucosa, showing the "tenting sign," "cushion sign," and the "naked fat sign."[10]
Surgery is the recommended course of management in adults because a causative lesion is present in most of the cases with a higher risk of malignancy.[3]
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
| Conclusion | | |
Intestinal intussusception in adults is a rare and challenging condition for the surgeon as it usually presents as acute abdomen and is usually not considered in preoperative differential diagnosis, without the classical triad seen in children. It is usually associated with an underlying cause which requires surgical intervention. Small bowel lipoma can present as intestinal obstruction due to intussusception. Abdominal CT is the diagnostic modality of choice.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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| 9. | Menegon Tasselli F, Urraro F, Sciaudone G, Bagaglini G, Pagliuca F, Reginelli A, et al. Colonic Lipoma Causing Bowel Intussusception: An Up-to-Date Systematic Review. J Clin Med 2021;10:5149. doi: 10.3390/jcm10215149. |
| 10. | Cheikhrouhou T, Dhaw MB, Zouari M, Zitouni H, Kallel R, Gouiaa N, et al. Small intestinal submucosal lipoma: A rare cause of secondary intussusception in a child. Ann Pediatr Surg 2021;17;47 https://doi.org/10.1186s43159-021-00114-7 |
[Figure 1], [Figure 2]
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