Colocolic Intussusception with Lipoma as Lead Point

A 25-year-old man, with no significant medical or surgical history, presented with a three-week history of left-sided, colicky abdominal pain which was aggravated by eating. It was associated with a four Kg weight loss and per rectum bleeding three days prior to presentation. Clinically, the patient looked well; his vital signs and haemodynamic parameters were stable. His abdomen revealed a mildly tender and mobile mass over the left lumbar area of c. 4 × 5 cm; the rest of the abdomen was soft. The abdominal computed tomography (CT) scan showed a c. 40 × 30 mm intra-mural lipoma in the descending colon with colocolic intussusception [Figure 1A and 1B]. The patient underwent a laparotomy and segmental colonic resection with primary anastomosis. The operative findings of the left colon indentified the presence of a lipoma in the left colon [Figure 2]. The histopathological examination of the mass confirmed the presence of a submucosal ulcerated lipoma.

Figure 1 A & B:

Coronal view of contrast abdominal CT scan (A) with presence of lipoma (arrow). B: Axial view showing the presence of an intra-mural lipoma in the descending colon with colocolic intussusception (arrow).

Figure 2:

Operative specimen showing the presence of an oval-shaped lipoma with yellow-reddish discoloration (arrow).

Comment

Approximately, 95% of all reported cases of intestinal intussusception present in childhood.1 The commonest ‘lead points’ for intussusception in adults, in up to 60% of cases, are colonic malignant tumours.2 Lipomas are the second most frequently occurring benign tumours of the large bowel, the commonest being adenomas.3

Adult intussusception does not have any specific clinical manifestations, but most have at least a one-month history of episodes of intermittent abdominal pain associated with vomiting.4 The diagnosis for colonic lipoma can be obtained by a combination of ultrasound examination, barium studies, a colonoscopy and CT scanning, the latter being the most sensitive test.5 The treatment of a symptomatic colonic lipoma is surgical resection; since most colonic lipomas are submucosal, endoscopic resection is seldom feasible.5 In general, colonoscopies may play a role as diagnostic and therapeutic tool, especially for an asymptomatic lipoma of less than two cm in size.7,8 Laparoscopic surgery has not yet been fully investigated as an alternative to open surgery because most patients with intussusception usually present in an emergency setting.6 However, conservative management (reduction with barium or air and close observation) is still an optional treatment of colocolic intussusception for younger age groups and patients for whom radiological investigations do not reveal a demonstrable anatomical ‘lead point’.7