Adult intussusception due to a colonic lipoma
Subgroup: Volume 10, Issue 1
Date: January 2008
Type: Case Report
Start Page: 41
End Page: 43
- AA Salari Department of Surgery, Shahid Sadoughi Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Yazd, Iran
- Sh Taghipoor Department of Pathology, Shahid Sadoughi Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Yazd, Iran
- AR Poormazar General practitioner, Shahid Sadoughi Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Yazd, Iran
City, Province: Yazd, Yazd
Colonic lipoma is a benign neoplasm that can lead to colonic obstruction but concomitant intussusception is rare in adults. In this case, colocolic intussusception due to a lipoma in descending colon occured. This was diagnosed using laparatomy, and any intervention to reduce it failed. So resection of the colon with mass and anastomosis were performed. After the surgery and 3 years of follow up, no complications were observed. We present this case, and briefly review the literature of colonic intussusception in adults.
Keywords: Colon; Lipoma; Intussusception; Adults; Obstruction
Colonic lipoma is a well-documented benign neoplasm; being more common in childhood (85%-95%) and concomitant intussusception in adults is rare, accounting for approximately 0.1% of hospital admissions and around 10% of all intussuceptons.1-8 Adult intusussception does not have any specific clinical manifestations. The majority of adults have a history of prior episodes of intermittent abdominal pain and vomiting for at least 1 month.8 The most common presenting symptoms are cramp abdominal pain (71%), nausea and vomiting (68%), and abdominal distention (45%).9,10 Patients usually present with signs and symptoms of intestinal obstruction.11 We report a case of colonic lipoma with colocolic intussusception, diagnosed by colonoscopy, computed tomography scans, barium enema and ultrasonography.
A 64 year old man was admitted to the hospital for a one year history of epigastric pain, constipation since 40 days before admission, weight loss, vomiting and abdominal distention. Abdominal ultrasonography showed a rounded 4-6 cm hyperechoic colonic mass. Computed tomography scanning revealed a lowdensity colonic tumor (Figs. 1 and 2), while barium enema demonstrated a tumor 5 cm in dimension in the descending colon. At colonoscopy, a large, smooth, ulcerated, yellow tumor was discovered in the descending colon together with a submucosal mass that was too large for endoscopic resection. Two days after the CT scan, the patient developed severe left upper and lower abdominal pain. Abdominal ultrasonography revealed a target-like pattern consisting of a round hyperechoic tumor surrounded by the intestinal wall.
Fig 1: Abodominal CT scan demonstrating lipoma at the neck of the intussusception (arrow).
Fig. 2: Abodominal Ctscan revealing the pathogonomonic bowel within Bowel configuration with lipoma (arrow)
Upon surgical exploration, the intussusception could not be relieved and reduced, because the mass was very large and occupied a large segment of descending colon after splenic flexture. So the patient underwent laparatomy and left hemicolectomy. On gross examination, there was a creamy-brownish colored ulcerated polypoid lesion 6x5x3 cm inside the lumen. On the cross section, the tumor appeared yellowish with a soft consistency. Histological examination revealed submucosal tumoral lesion composed of lobulated mature adipose tissue with areas of fibrosis, infiltration of foamy cells and calcifications.
Colonic lipoma is the second most common benign large bowel tumor, after adenoma.12,13 Tumors located in the right colon, particularly in the cecum, account for 70% of colonic lipoma.14 Lipomas<2 cm are usually asymptomatic and are usually removable endoscopically,15 but those greater than 2-4 cm in diameter are more likely to produce clinical signs and symptoms.14 Furthermore, lipomas>4 cm may produce troublesome symptoms including obstruction or intussusception.16,17 Symptomatic large colonic lipomas require surgical intervention.18-24 Adult patients with symptoms of intussusception usually have a neoplasm in the wall of the colon, and usually have large benign lipomas, with two-thirds of tumors in the right colon.22 Those between 4-7 cm in diameter are associated with intussusception.25 Computed tomography scans of colonic lipomas can provide a definitive diagnosis because the mass typically has characteristic fatty densitometric values. However, these features are evident only in large lesions, so smaller tumors are not detected due to artifacts and partial volume averaging.26-28
Colonoscopy can usually distinguish lipoma from other tumors. Lipomas appear as smooth, round yellowish polypoid lesions with a thick stalk or broad based attachment. Characteristic features include the ‘cushion sign’ and the ‘naked fat sign’.16 Rare complications of lipoma such as self amputation and malignant transformation (liposarcoma) have been reported.29 The definitive treatment of symptomatic colonic lipoma is surgical resection. Endoscopic resection is seldom feasible because most colonic lipomas are submucosal. Endoscopic removal of small colonic lipoma with snare cautery has been described but this is a technically difficult procedure with an appreciable incidence of perforation (43%).15 In summary, the preferred treatment of symptomatic intussusception due to a colonic lipoma is surgical resection without manipulation or reduction before clinical problems are encountered.11
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- Alponat A, Kok KY, Goh PM, Ngoi SS. Intermittent subacute intestinal obstruction due to giant lipoma of the colon a case report. Am Surg 1996;62:918-21.
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- Khurrum Baig M, Hussain S, Wise M, Wexner SD. Controversy in the treatment of adult long ileocolic intussusception case report. Am Surg 2000;66:742-3.
- Pourohit V, Joshi R, Kallh AR, Purohit RC. Colo-colic intussusception due to intestinal lipomatosis. Indian Gastroenterol 2003;22:151-2.
- Buetow PC, Buck JL, Carr NJ, Pantongrag- Brown L, Ros PR, Cruess DF. Intussuscepted colonic lipomas: loss of fat attenuation on CT with pathologic correlation in 10 cases. Abdom Imaging 1996;21:153-9.
- Rosier A, de Canniere L, Frangi R, Michel La. Early Diagnosis of Adult Intestinal Intussuscention At Four Different Locations. Acta Chir Belg 1994;94:314-7.
- Megibow AJ, Redmond PE, Bosniak MA, Horowitz L. Diagnosis of gastrointestinal lipoma by CT. AJR 1979;133:743-5.
- Crozier F, Portier F, Wilshire P, Navarro Biou A, Panuel M. CT scandiagnosis of colo-colic intussusception due to a lipoma of the left colon. Ann Chir 2002;127:59-61.
- Radhi JM. Lipoma of the colon self amputation. Am J Gastroentrol 1993;88:981-2.