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An Intestinal Lipoma Presenting as a Case of Intussusception |
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Ipsita Acharya, Sanjib Das 1. Junior Resident, Department of Radiodiagnosis, SCB Medical College and Hospital, Cuttack, Odisha, India. 2. Junior Resident, Department of Radiodiagnosis, SCB Medical College and Hospital, Cuttack, Odisha, India. |
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Correspondence Address : Dr. Sanjib Das, OGH Room No-31, SCB Medical College, Mangalabag, Cuttack, Odisha-753007, India. E-mail: sanjib1988@gmail.com |
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| ABSTRACT |  | ||||||||||||||||||
: Intussusception is a process of invagination of proximal bowel into distal part. Although, most of the cases in children are idiopathic. Neoplasms (benign or malignant) are the most common causes reported in the adults. Small bowel intussusceptions are most commonly associated with benign neoplasms (like lipoma, leiomyoma, hemangioma or neurofibroma) and other causes like adhesions and lymphoid hyperplasia. On contrary, large bowel intussusceptions are mostly associated with malignant neoplasms. We present a case of colo-colonic intussusception in a 58-year-old male patient of Indian origin with features of vague abdominal pain for two months, occasional vomiting and mucoid stool for same period of time with an intestinal lipoma being the lead point. | |||||||||||||||||||
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| Keywords : Benign colonic tumour, bowel within bowel, Neoplasms[ | |||||||||||||||||||
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DOI and Others :
DOI: 10.7860/IJARS/2017/31655:2327
FINANCIAL OR OTHER COMPETING INTERESTS: None. Date of Publishing: Oct 01, 2017 |
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| Case Report |
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A 58-year-old male patient presented to Department of Surgery with vague abdominal pain, occasional vomiting and mucoid stool for two months. There was no history of blood in stool. On physical examination, mild tenderness in epigastric region was noted. There was no symptom of intestinal obstruction. He admitted taking some PPIs and antacids. On X-ray, meniscus sign (crescent of air outlining the intussusceptum) was noted in the transverse colon region suggesting a possible diagnosis of colo-colic intussusceptions (Table/Fig 1). On USG bowel within bowel appearance was visualized suggesting intussusceptions (Table/Fig 2). On careful imaging a rounded echogenic lesion was noted at the distal end of the intussusception. A contrast enhanced CT-scan was advised which revealed a lobulated lesion of fatty attenuation suggesting a lipoma which triggered the intussusceptions (Table/Fig 3),(Table/Fig 4),(Table/Fig 5),(Table/Fig 6). The patient underwent limited resection of the bowel with end to end anastomosis . | |||||||||||||||||||
| Discussion |
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Intussusception is the invagination of a segment of proximal bowel into the adjacent distal bowel. It is more common in children, being the most common cause of intestinal obstruction in children aged between three months to six years (1). It is rare in adults accounting for only 1% cases of intestinal obstruction (1),(2),(3). Intussusceptions are classified on the basis of their location into four groups: enteroenteric, ileocolic, ileocaecal and colocolic (2),(4). About 90% of cases of adult intussusception are caused by an underlying organic pathology and only 10% cases are deemed to be idiopathic (1),(4),(5). Common causes of intussusception in adults are neoplasms, adhesions, chronic diarrhoea and motility disorders like Hirschsprung’s disease, irritable bowel syndrome etc., [1,6]. Neoplasms whether benign or malignant account for 65% of adult intussusceptions (3). Intussusceptions are more common in small bowel accounting for 66% of cases while large gut constitutes the rest. Small bowel intussusceptions are most commonly associated with benign neoplasms like lipoma, leiomyoma, hemangioma or neurofibroma and other causes like adhesions and lymphoid hyperplasia. On contrary, large bowel intussusceptions are mostly associated with malignant neoplasms (65%) with the rest being constituted by benign lesions like lipoma and adenoma (1),(3). Lipomas are the second most common benign lesions of colon after adenoma though it represents the most common benign cause of large bowel intussusceptions (4),(5). Most patients follows, a subacute or chronic course with nonspecific symptoms like abdominal pain, nausea, bilous vomiting and rarely bloody stool mixed with mucus (also known as currant jelly stool) (1),(4),(5). Diagnosis Plain radiograph: Usually there is normal bowel appearance. Sometimes however, there can be a crescent of air outlining the intussusceptum called “meniscus sign”. Barium study: On barium studies, accumulation of contrast between the intussusceptum and intussuscipiens produces ring shadows which represent “the coiled spring sign”. Another sign seen is the “claw sign” in which the barium in the intussuscipiens is seen as a claw around the negative shadow of the intussusceptum (7). USG: On longitudinal imaging, telescoping of bowel loops can easily be visualized mimicking the appearance of a kidney (pseudo-kidney or sandwich sign). On axial view, bowel within bowel appearance is noted (Target-sign/Doughnut-sign) (8). USG should be directed at finding any lead point triggering the intussusceptions. Mesenteric fat may sometimes be confused with a lipoma which can be differentiated by the traversing mesenteric vessels. CT-scan: CT-scan appears to be the modality of choice with sensitivity of approximately 80% and specificity close to 100% [5,7]. In longitudinal scans, the sausage shaped mass appearance is characteristic while in axial scan, target mass is noted. Often there is mesenteric fat surrounding the intussusceptum containing blood vessels. CT is useful to find out the lead point; however it’s not always detected. Lipoma on CT images appears as a well marginated spherical or oval mass of fat attenuation with no blood vessels within unlike mesenteric fat (4),(7),(8). CT is also valuable prior to surgery to detect any vascular compromise or for the detection of gas in the intussusceptum which might indicate perforation or gangrene (8). Transient intussusceptions without any leading cause can also occur where mesenteric fat may sometimes be confused with a lipoma. Limited resection of the intussusceptions is the treatment of choice. Colonoscopic reduction can sometimes be used (1). | |||||||||||||||||||
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