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CASE REPORT
Year : 2014  |  Volume : 2  |  Issue : 2  |  Page : 63-65

Colonic lipoma causing colo-colic intussusception


Department of General Surgery, Sree Narayana Institute of Medical Sciences, Ernakulam District, Kerala, India

Date of Web Publication12-Sep-2014

Correspondence Address:
Abdulla Askar Babu
Department of General Surgery, Sree Narayana Institute of Medical Sciences, Chalakka, North Kuthiyathodu P.O., Ernakulam District, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3846.140696

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  Abstract 

A 32-year-old female patient is presenting with severe right upper quadrant abdominal pain and vomiting. On examination, she had tenderness in the epigastrium, apart from this there were no other positive findings on examination. The clinical diagnosis of acute cholecystitis was made. Her routine investigations were noncontributory. Ultrasound scan of the abdomen revealed thickening of the bowel wall in the region of the hepatic flexure. A contrast enhanced computed tomography of the abdomen was suggestive of ileo-colic intussusception with a lipoma as the lead point. Intraoperatively, she had a colo-colic intussusception involving the ascending colon and the right half of the transverse colon. A pedunculated polyp in the region of the hepatic flexure was the lead point and seen to be obstructing the lumen completely. She underwent a right hemi colectomy with an ileo-transverse anastomosis. Her postoperative recovery was uneventful, and she was discharged on the 5 th postoperative day. The histopathological examination confirmed the polyp to be of the submucouslipomatous variety.

Keywords: Anastomosis, hemicolectomy, intussusception, lipoma, pedunculated


How to cite this article:
Prabhu SG, Babu AA, Joseph S. Colonic lipoma causing colo-colic intussusception . Saudi Surg J 2014;2:63-5

How to cite this URL:
Prabhu SG, Babu AA, Joseph S. Colonic lipoma causing colo-colic intussusception . Saudi Surg J [serial online] 2014 [cited 2022 Aug 16];2:63-5. Available from: https://www.saudisurgj.org/text.asp?2014/2/2/63/140696


  Introduction Top


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. 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 crampy abdominal pain, nauseaand vomiting, and abdominal distention.Patients usually present with signs and symptoms of intestinal obstruction. We report a case of colonic lipoma with colocolic intussusception


  Case Report Top


A 32-year-old female patient presented to us with a history of severe right upper quadrant abdominal pain and vomiting of 4 days duration. Her bowel habits were normal. She had the similar complaints on and off for the past 1 month. The menstrual history was normal, and she had undergone an ultrasonogram 2 weeks back which was normal. She had tenderness in the epigastrium, apart from this there were no other positive findings on examination. The clinical diagnosis of acute cholecystitis was made and the patient was admitted for stabilization and further evaluation.

Her routine investigations were noncontributory. An ultrasound scan of the abdomen revealed thickening of the bowel wall in the region of the hepatic flexure. A contrast enhanced computed tomography of the abdomen was suggestive of ileo-colic intussusception with a lipoma as the lead point [Figure 1].
Figure 1: Computed tomography images of the case

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After routine preoperative evaluation, she was taken up for an exploratory laparatomy. Her intraoperative findings showed a colo-colic intussusception involving the ascending colon and the right half of the transverse colon [Figure 2] and [Figure 3]. A pedunculated polyp in the region of the hepatic flexure was the lead point and seen to be obstructing the lumen completely [Figure 4]. We proceeded with a formal right hemi colectomy with an ileo-transverse anastomosis.
Figure 2: Lesion intraoperatively

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Figure 3: Resected specimen

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Figure 4: Intraluminal submucouslipomatous polyp

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Her postoperative recovery was uneventful, and she was discharged on the 5 th postoperative day. She was asymptomatic and did fine on her subsequent reviews. The histopathological examination confirmed the polyp to be of the submucouslipomatous variety.


  Discussion Top


Intussusception remains a rare condition in adults, representing 1% of bowel obstructions or

0.003-0.02% of all hospital admissions. [1] In contrast to a pediatric intussusception (which is mainly of unclear etiology), adult intussusception in 90% of cases is secondary to an organic lesion within the bowel wall. [2],[3],[4],[5] Although the mechanism of development is unknown, it is believed that any lesion in the intestinal wall or irritant within the lumen that alters normal peristalsis can initiate an invagination. [2],[6] There are different classification systems of intussusceptions. In general, intussusception is classified as enteric or colonic according to the location of the pathologic lead point. [7] The enteric group includes jejunojejunal, ileoileal, and ileo-colic intussusceptions, whereas the colonic group includes ileocecal-colic, colo-colic, sigmoidorectal, and appendicicocecal intussusceptions. Ileo-colic and ileocecal-colic intussusceptions are distinguished by the site of the pathologic lead point. In ileo-colic intussusception, the lead point is in the ileum, but in ileocecal-colic intussusception the lead point is in the ileocecal valve. However, in clinical practice, it is difficult to differentiate some of the complicated advanced forms of ileocecal-colic intussusceptions. [8]

Adult intussusception presents with a variety of nonspecific symptoms that can have an acute, intermittent, or chronic course. Since only about 9-10% of adult intussusceptions present with the typical triad of abdominal pain, palpable abdominal mass and bloody stool, the preoperative diagnosis is usually very difficult. [2] Early and accurate diagnosis is essential because a delay can lead to intestinal ischemia, perforation, and peritonitis and result in a potentially fatal outcome. [9],[10],[11] A number of different diagnostic methods - such as computed tomography (CT) scan, barium imaging, abdominal ultrasound, endoscopic examination, and angiographic and radionucleotide studies - have been described as useful in the diagnosis of intussusceptions. [12],[13] The abdominal CT scan has been proven to be the most useful diagnostic method, and ultrasound is the second most accurate; both reveal a characteristic "target" or "sausage" - shape mass.

The treatment of intussusception in adults is surgical because of the high incidence of underlying malignant pathology and serious complications that can develop as a result of intestinal obstruction and vascular strangulation. [2],[6] Most surgeons agree that the resection is necessary, particularly in colonic intussusceptions and in older patients, because of the possibility of a malignant tumor. [1],[4],[14] It remains debatable whether reduction of the intussuscepting lesion should be attempted during an operation or whether "en bloc" resection should be carried out without attempting reduction. [9],[14] Previous reports advocated reducing the intussusception before resection. [15],[16] Some authors have recommended a selective approach to resection, depending on the site of intussusception, which influences the type of pathology. [12],[14] Chang et al. [17] recommended operative reduction for small-bowel intussusceptions but not for colonic intussusceptions. Gupta et al. [18] reported resection in 70% of colonic intussusceptions. The potential disadvantages of this approach are intraluminal seeding and tumor dissemination via venous flow, perforation and seeding of infection and tumor cells into the peritoneal cavity, and increased risk of anastomotic complications. [19] The advantages of the intraoperative reduction of the intussusception prior to resection, especially when the small-bowel is affected, are that it may preserve a considerable length of boweland, thereby prevent the development of short-bowel syndrome. Yalamarthi et al. [8] are proponents of resection without attempting reduction when the bowel is inflamed, ischemic, or friable and in obvious colo-colic intussusception (with the high likelihood of malignancy). In all other cases, reduction should always be attempted initially.

The postoperative complication rate in adult intussusceptions is still reported by some authors [6],[17] to be relatively high. Although there is no existing research on a large group of patients, complications are much more a consequence of missed diagnosis and delayed treatment than the result of anastomotic problems, according to current studies. [2],[6],[17] Bar-Ziv and Solomon [12] (2009), in their retrospective study, reported a 20% postoperative complication rate and a perioperative death rate of 5% due to severe sepsis complicated by multiple organ failures 6 days after the operation, but there was no leak of anastomosis. Furthermore, Chang et al. [17] reported a postoperative death rate of 5.5% in adult intussusceptions treated surgically.


  Conclusion Top


The diagnosis of intussusception in adults can be difficult because of atypical and episodic symptoms. It is very important to intervene surgically early on. A high level of clinical suspicion and an abdominal CT scan are most useful tools for making a timely diagnosis.

 
  References Top

1.Eisen LK, Cunningham JD, Aufses AH Jr. Intussusception in adults: Institutional review. J Am Coll Surg 1999;188:390-5.  Back to cited text no. 1
    
2.Wang N, Cui XY, Liu Y, Long J, Xu YH, Guo RX, et al. Adult intussusception: A retrospective review of 41 cases. World J Gastroenterol 2009;15:3303-8.  Back to cited text no. 2
    
3.Peh WC, Khong PL, Lam C, Chan KL, Saing H, Cheng W, et al. Ileoileocolic intussusception in children: Diagnosis and significance. Br J Radiol 1997;70:891-6.  Back to cited text no. 3
    
4.Azar T, Berger DL. Adult intussusception. Ann Surg 1997;226:134-8.  Back to cited text no. 4
    
5.Agha FP. Intussusception in adults. AJR Am J Roentgenol 1986;146:527-31.  Back to cited text no. 5
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6.Zubaidi A, Al-Saif F, Silverman R. Adult intussusception: A retrospective review. Dis Colon Rectum 2006;49:1546-51.  Back to cited text no. 6
    
7.Yakan S, Caliskan C, Makay O, Denecli AG, Korkut MA. Intussusception in adults: Clinical characteristics, diagnosis and operative strategies. World J Gastroenterol 2009;15:1985-9.  Back to cited text no. 7
    
8.Yalamarthi S, Smith RC. Adult intussusception: Case reports and review of literature. Postgrad Med J 2005;81:174-7.  Back to cited text no. 8
    
9.Begos DG, Sandor A, Modlin IM. The diagnosis and management of adult intussusception. Am J Surg 1997;173:88-94.  Back to cited text no. 9
    
10.Erkan N, Haciyanli M, Yildirim M, Sayhan H, Vardar E, Polat AF. Intussusception in adults: An unusual and challenging condition for surgeons. Int J Colorectal Dis 2005;20:452-6.  Back to cited text no. 10
    
11.Hurwitz LM, Gertler SL. Colonoscopic diagnosis of ileocolic intussusception. Gastrointest Endosc 1986;32:217-8.  Back to cited text no. 11
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12.Bar-Ziv J, Solomon A. Computed tomography in adult intussusception. Gastrointest Radiol 1991;16:264-6.  Back to cited text no. 12
    
13.Montali G, Croce F, De Pra L, Solbiati L. Intussusception of the bowel: A new sonographic pattern. Br J Radiol 1983;56:621-3.  Back to cited text no. 13
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14.Balik AA, Ozturk G, Aydinli B, Alper F, Gumus H, Yildirgan MI, et al. Intussusception in adults. Acta Chir Belg 2006;106:409-12.  Back to cited text no. 14
    
15.Donhauser JL, Kelly EC. Intussusception in the adult. Am J Surg 1950;79:673-7.  Back to cited text no. 15
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16.Brayton D, Norris WJ. Intussusception in adults. Am J Surg 1954;88:32-43.  Back to cited text no. 16
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17.Chang CC, Chen YY, Chen YF, Lin CN, Yen HH, Lou HY. Adult intussusception in Asians: Clinical presentations, diagnosis, and treatment. J Gastroenterol Hepatol 2007;22:1767-71.  Back to cited text no. 17
    
18.Gupta RK, Agrawal CS, Yadav R, Bajracharya A, Sah PL. Intussusception in adults: Institutional review. Int J Surg 2011;9:91-5.  Back to cited text no. 18
    
19.Marinis A, Yiallourou A, Samanides L, Dafnios N, Anastasopoulos G, Vassiliou I, et al. Intussusception of the bowel in adults: A review. World J Gastroenterol 2009;15:407-11.  Back to cited text no. 19
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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