Introduction
Adult intussusception is rare and represents only about 5% of all intussusception
with variable clinical presentation.[1] The classic triad of crampy abdominal pain, bloody (“currant jelly”) stool and a
palpable mass of acute intussusception as pediatric presentation is rare. Colonic
lipomas are rare submucosal benign tumor. Colonic lipomas are usually asymptomatic,
but lipomas> 2 cm can rarely present with intussusception.
Case Report
A 53-year-old male with no previous comorbidities, presented with 2-month history
of increased stool frequency and occasional mild abdominal discomfort. Patient stool
frequency was 3–4/day. Stool was liquid to semisolid in consistency, small volume,
and easy to flush. No history of hematochezia, melena, fever, loss of weight, loss
of appetite, nocturnal awakening, and incontinence. There was a history of occasional,
mild, self-limiting abdominal discomfort. There was no history of constipation, obstipation,
or vomiting. His physical examination was within normal limits. He was given 3-day
course of ofloxacin 200 mg and ornidazole 500 mg twice daily for 3 days in an outside
medical facility. He had no relief in symptoms with above medication. He was evaluated
in our clinic for chronic diarrhea. His investigations revealed hemoglobin of 14.6
g% with normocytic normochromic red blood cells, normal leukocyte and platelet count,
and normal renal and liver biochemistry. His thyroid function test and serum IgA tissue
transglutaminase titer were within normal limit. He was nonreactive for HIV ELISA.
Stool routine microscopy did not show any parasite and pus cells on consecutive three
stool samples. Colonoscopy was performed to rule out suspicion of microscopic or Crohn's
colitis. Colonoscopy revealed a large polypoidal smooth surfaced rounded lesion at
splenic flexure with severe narrowing of lumen [Figure 1]a and [Figure 1]b. Scope was not negotiable across. Biopsy was taken from the head of polypoid lesion
and also from rectosigmoid. Histopathological examination from polypoid lesion was
suggestive of lipoma, whereas histopathological examination of the biopsy from rectosigmoid
was normal. Possibility of intussusception was kept and abdominal Contrast-enhanced
computed tomography (CECT) performed. CECT Abdomen revealed 3.8 cm × 2.8 cm sized
well-defined fat density lesion within the lumen of splenic flexure of colon, with
resultant colocolic intussusception without any suggestion of obstruction [Figure 2]a and [Figure 2]b. Hence, diagnosis of colocolic intussusception with colonic lipoma as lead point
was made.
Figure 1(a) Large white arrow showing intussuscipien, small white arrow showing intussusceptum,
arrowhead showing lead point lipoma. (b) Transition between the lead point lipoma
and intussuscepted colonic segment, arrowhead showing biopsy being taken from lead
point
Figure 2(a) sausage shaped mass with layering effect suggestive of colo-colic intussusceptions
at proximal splenic flexure. (b) 3.8 cm × 2.8 cm sized fat density lesion within lumen
of splenic flexure of colon acting as lead point for intussusception
Patient underwent open surgery, which confirmed the diagnosis of colocolonic intussusception
with large lipoma as lead point. Resection of involved segment of colon along with
primary anastomosis was done. Histological examination of resected specimen confirmed
lipoma. Patient was discharged after 5 days and was symptom free.
Discussion
Intussusception occurs when one segment of the gastrointestinal tract (intussusceptum)
telescopes into the lumen of an adjacent distal segment of the gastrointestinal tract
(intussuscipiens). Adult intussusception is a rare clinical entity and represents
only about 5% of all intussusception.[1] It is the cause of 1%–3% of all cases of intestinal obstructions.[2] The mean age at diagnosis is 54.4 years, and the male-to-female ratio is 1:1.3.[3]
Adult intussusception presenting symptoms are often nonspecific and chronic, consistent
with partial obstruction.[3] Abdominal pain and distension, nausea, vomiting, gastrointestinal bleeding, constipation,
and changes in bowel habits are common presenting symptoms.[4] Fever, weight loss, constipation, and diarrhea are infrequent. A palpable abdominal
mass is present in <10% of the patients. Bloody stool is seen only in one-quarter
of the patient.[3] Dance's sign (apparent right iliac fossa “emptiness”) is only occasionally appreciable.
The clinical features also have an association with the underlying pathological lesion's
nature and site and the presence or absence of a lead point.[3] The mean duration of symptoms is longer in benign as compared with malignant lesions
and in enteric as compared with colonic lesions.
According to location, intussusception classified into four types including ileocolic,
ileo-ileo-colic, colocolic, and small bowel intussusception (jejuno-jejunal and ileo-ileal).[5] In adults, often there is an underlying trigger or nidus for the intussusception
in around 90%–95% of the cases.[6] The majority of lead points in the small intestine consist of benign lesions, whereas
in large bowel, majority consist of malignant lesion.[7]
Colonic lipomas are rare submucosal benign tumor and are usually asymptomatic. Most
cases are found incidentally during colonoscopy, surgery, or autopsy.[8] Signs and symptoms are generally related with lipomas> 2 cm and include abdominal
pain, constipation, rectal hemorrhage, and rarely intussusception.[8] Lipoma of the colon is predominantly localized in ascending colon (61% from the
reported cases), followed by descending colon (20.1%), transverse colon (15.5%), and
in the rectum (3.4%). Considering that lipomas are most often located in the ascending
colon, we present a rare case of a colonic lipoma of the left colon leading to colocolic
intussusception.
Abdominal CT is the most useful diagnostic tool not only for detecting an intussusception
with a diagnostic yield of around 78% but also helps in identifying the underlying
cause.[9] The characteristic features include a heterogeneous “target” or “sausage-shaped”
soft tissue mass with a layering effect. Mesenteric vessels within the bowel lumen
are also typical. Plain abdominal X-rays and ultrasound are of limited diagnostic
value in adults.
Colonoscopy is valuable not only for confirmation of the intussusception but also
help in its localization, demonstration of the underlying organic lesion serving as
a lead point, and possible treatment. Endoscopic findings that are characteristic
of lipoma are “cushion sign” (forcing the forceps against the lesion results in depression
and then restoration of the mass) and “naked fat sign” (fat extrusion during the biopsy).[8]
Treatment is almost always surgical in adults when compared to children and invariably
leads to resection of the involved bowel segment with subsequent primary anastomosis.
Majority of authors recommend surgery as the standard method of treatment for every
colonic lipoma> 2 cm in size.[8] Surgical treatment includes resection, colotomy with local excision, limited colon
resection, segmental resection, hemicolectomy, or subtotal colectomy. The choice of
the surgical intervention mainly depends on the lipoma size, location, and the presence
or absence of definite preoperative diagnosis. Few cases of successful laparoscopic
resection of colonic lipomas have been reported in literature. It is recommended to
use laparoscopic resection in the face of a known lipoma because the patient enjoys
the benefit of shorter period of ileus, shortened disability, less postoperative pain,
and shorter hospital stay.[8]
Endoscopic mucosal resection using the electrocautery snare is preferred technique
for the excision of lipomas smaller than 2 cm in size. However, endoscopic removal
of sessile or broadly based lipomas may result in a high rate of perforation and hemorrhage.
Although intussusception themselves have a good prognosis, it is often the nature
of the lesion causing the intussusception which determine prognosis. Mortality for
adult intussusception increases from 8.7% for the benign lesions to 52.4% for the
malignant variety.[2]
Conclusion
Adult intussusception is rare and presenting symptoms are often nonspecific and chronic
which can lead to delay in diagnosis. Often an underlying trigger or nidus is present
in adult intussusception and treatment is almost always surgical. Therefore, keeping
a high index of suspicion combined with early diagnosis with colonoscopy or CT scan
can prevent serious complications such as hemorrhage, intestinal gangrene, and perforation.
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