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Intussusception in adults accounts for less than 5% of all intussusceptions. It occurs when a segment of intestine invaginates into itself.
We report a case of ileocolic intussusception in an adult caused by a giant ileal lipoma.
Intussusceptions can be classified as ileocolic, ileocecal, colo-colic and ileo-ileal. Most are due to neoplasms (60% malign and 24–40% benign). In the colon, the possibility of malignancy is higher than in small intestine.
Lipomas are the most common benign mesenchymal intestinal tumors, accounting for less than 5% of all gastrointestinal tumors. They are more frequent in colon than small intestine. Small lipomas (less than 2 cm) are usually asymptomatic. Larger lesions may produce symptoms such as abdominal pain, obstruction or intussusception. Lipomas can be diagnosed with endoscopy, capsule endoscopy, barium enemas, CT and US.
Intussusceptions in adults is a rare condition, most of them are caused by a malign neoplasms followed by benign neoplasms. US and CT are useful for diagnosis. Surgery is mandatory.
Intussusception in adults is rare, accounting for less than 5% of all cases of intussusceptions, and 1–2% of bowel obstructions.1,2 Most adult intussusceptions have an organic cause.3 Preoperative diagnosis is difficult. CT and US can be used and typical “sausage-like” or “target-like” images can be seen.2,3 An etiological diagnosis is advisable.
Lipomas are the most common benign mesenchymal tumors found in the gastrointestinal tract. They are more frequent in colon than small bowel.4 Small lipomas are asymptomatic but lesions exceeding 2 cm diameter can cause non specific clinical manifestations or, rarely, acute symptoms such as intussusception or hemorrhage which require surgery.5
We report a rare case of giant ileal lipoma which caused ileocolic intussusception and required urgent surgery.
A 75 year old male with a history of hypertension was admitted with abdominal pain and vomiting of days duration together with diarrhea for three months. The patient was apyrexial and hemodynamically stable. A tender mass was palpable in the periumbilical area of his abdomen. His white blood cell count was 12,000/μL while his hemoglobin was slightly low (12 g/dL). Plain abdominal X ray revealed distended small bowel loops. An ultrasound demonstrated a typical image of intussusception, confirmed on CT scanning. With the diagnosis of ileocolic intussusception, the patient underwent urgent surgery. A laparotomy was performed revealing an ileocolic intussusception caused by a giant tumor measuring 6 cm diameter. The intussusception extended from ileum to transverse colon. A gangrenous appendicitis was found as well, due to rotation of the meso-appendix due to intussusception (see Figs. 1–3).
An oncological right hemicolectomy was performed. The intussusception was not reduced given the suspicion of a malignant process. An ileo-transverse colic anastomosis was carried out. The histopathology exam revealed a 5.5 cm submucosal lipoma in the ileum, an ileocolic invagination of 20 cm and confirmed a gangrenous appendicitis. No evidence of dysplasia or malignancy was found. The patient was discharged complication-free 9 days after surgery and remains well.
90% of adult intussusceptions have an organic cause, 60% developing due to neoplasms (60% malign and 24–40% benign).2,3,6 The average age is 51 and they are slightly more frequent in women.2 Adult colonic intussusception is caused by a primary carcinoma in 65–70% of all cases, and small bowel intussusception is associated with malignant process in 30–35% of all cases.2 Intussusceptions can be divided into four groups: enteric, ileocolic, ileocecal and colonic. Ileocolic constitute 15% of all intussusceptions.1 Most ileocolic intussusceptions are due to malignancy, most commonly lymphomas followed by adenocarcinomas.2
The clinical presentation of intussusceptions can be very diverse in the adult. Abdominal pain is the most common symptom followed by obstruction and palpable mass.2,6 Diagnosis can be achieved with adequate techniques such as US and CT. Yet, etiological preoperative diagnosis is difficult.1 CT has a sensitivity of 58–100% and a specificity of 57–71% in determining the etiology; a “target sign” or a “sausage shaped” mass with different layers of attenuation can be shown in CT.2,6 US is easy to perform and non-invasive, especially useful in children. Classic features like “target”, “donut” signs or pseudokidney can be revealed on US but image interpretation can be difficult in presence of air.6
Gastrointestinal lipomas are benign tumors first reported in 1757 by Bauer.5 They usually arise from the adipocytes in the submucosa (90%) and occasionally in the subserosa.4,5 Lipomas account for 5% of all gastrointestinal tumors. They are the second most common benign tumors in the small intestine; and the third most common benign neoplasm in the colon following hyperplasic and adenomatous polyps.1,5 Lipomas are found most commonly in the colon (65–75%),especially in the right side followed by transverse colon, descending colon, sigmoid and rectum. 20–25% occur in the small intestine (most frequently ileum).1,4,5 Small lipomas are usually asymptomatic and only casually detected in colonoscopy or surgery. Lipomas exceeding 2 cm diameter usually produce unspecific symptoms such as abdominal pain, diarrhea, or in rare cases acute clinical manifestations due to intussusception or bleeding.3–5 In the case we report the patient related a history of three months of diarrhea before developing intestinal obstruction.
Lipomas can be diagnosed with endoscopy, capsule endoscopy, barium enemas, CT, US. Endoscopy can show a smooth yellow surface with a pedunculated or sessile base or either the “cushion-sign” or “naked fat sign”. CT reveals a “sausage” like shaped mass and intussusception can be showed and confirmed on contrast enema (“crescent sign”).1 The most important point in the diagnosis of intestinal lipomas is that it must be distinguished from a malignant colonic neoplasm, so the gold standard of diagnosis is the histopathology exam.5 Urgent surgery is mandatory in case of intussusceptions, perforation or bleeding. The treatment of intussusceptions in adults is surgical. There is a high risk of a malignant neoplasm so it is not advisable to attempt reduction.3,5
In conclusion, intussusception in adults is rare. Most cases have an organic cause, and most are malignant. Symptoms can be vague and diagnosis delayed. US and CT are useful. Surgery is mandatory.
The authors have no conflict of interest.
No study sponsors involved.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Ana María Minaya Bravo: study design and data collection.
Cristina Vera Mansilla: data collection and interpretation of data.
Fernando Noguerales Fraguas: draft of the article and review.
Francisco Javier Granell Vicent: review.