Open Access

Adult intussusceptions caused by a lipoma in the jejunum: report of a case and review of the literature

  • Ouadii Mouaqit1Email author,
  • Hafid Hasnai1,
  • Leila Chbani2,
  • Bachir Benjelloun1,
  • Hicham El Bouhaddouti1,
  • Karim Ibn el Majdoub1,
  • Imane Toughrai1,
  • Said Ait Laalim1,
  • Abdelmalek Oussaden1,
  • Khalid Maazaz1,
  • Afaf Amarti2 and
  • Khalid Ait Taleb1
World Journal of Emergency Surgery20127:28

DOI: 10.1186/1749-7922-7-28

Received: 12 April 2012

Accepted: 16 August 2012

Published: 22 August 2012

Abstract

Intussusceptions in adults is rare. Gastrointestinal lipomas are rare benign tumors and intussusceptions due to a gastrointestinal lipoma constitutes an infrequent clinical entity. Lipoma may develop as a benign tumor in all organs and rarely in large or small intestine. The present report describes a case of jejunojejunal intussusceptions in an adult with a history of colicky upper abdominal pain. Ileo-ileal invagination was diagnosed by computed tomography scan. Exploratory laparotomy revealed jejunojejunal intussusceptions secondary to a lipoma which was successfully treated with segmental intestinal resection. A review of the literature is also performed regarding this rare association revealing the diagnostic and therapeutic debates that exist.

Abstract (french)

L’invagination chez les adultes est rare. Les lipomes gastro-intestinaux sont de rares tumeurs bénignes et l’invagination intestinale due à un lipome gastro-intestinal constitue une entité clinique trés rare. Le lipome peut se développer comme une tumeur bénigne dans tous les organes et rarement dans l’intestin grêle ou le colon. Le présent rapport décrit un cas d’invagination jéjunojéjunale chez un adulte avec une histoire de douleurs abdominales. Iléo-iléale invagination a été diagnostiquée par tomodensitométrie. Une laparotomie exploratrice a révélé l’existence d’une invagination jéjunojéjunale secondaire à un lipome qui a été traitée avec succès par une résection intestinale segmentaire. Une revue de la littérature est également effectuée au sujet de cette association rare révélant les débats diagnostiques et thérapeutiques qui existent.

Keywords

Intussusceptions Jéjunal lipoma Intestinal tumor Surgery

Background

Intussusceptions was reported for the first time in 1674 by Barbette of Amsterdam[1]. The occurrence of intussusceptions in adults is rare, accounting for less than 5% of all cases of intussusceptions and almost 1%-5% of bowel obstruction[2]. In contrast to pediatric intussusceptions, which is idiopathic in 90% of cases, adult intussusceptions has an organic lesion in 70% to 90% of cases[3]. The majority of lipomas in the small bowel are solitary. Approximately 5% are multiple[4]. Symptomatic lipoma manifestations are hemorrhage or intestinal obstruction. Due to their intramural location, lipomas can also serve as the leading point for intussusceptions. We report a rare case of jejuno-jejunal intussusceptions in an adult secondary to an jejunal lipoma.

Case presentation

A 35-year-old man was admitted to the emergency department in a tertiary referral hospital with 4 months history of intermittent upper abdominal pain accompanied with nausea. The patient had no past history of peptic ulcer disease, alteration in bowel habits, melena or weight loss. On examination, he was apyrexial and hemodynamically stable. His abdomen was distended and no palpable abdominal masses; bowel sounds were hyper audible. Initial A rectal examination revealed no masses or blood. Laboratory blood tests were normal. Abdominal radiography revealed prominent dilatation of the small bowel with air fluid levels (Figure 1). Abdominal CT showed a target sign- or sausage-shaped lesion typical of an intussusceptions that varied in appearance relative to the slice axis (Figure 2). The inner central area represented the invigilated intussuscepted, surrounded by its mesenteric fat and associated vasculature, and all surrounded by the thick-walled intussuscipiens. More head-side scans showed a low-density homogenous mass measuring 4 cm that was considered to be the leading point for the invagination (Figure 3). These findings led to a diagnosis of intussusceptions induced by a tumor most likely begin. The decision was made to undertake an urgent exploratory laparotomy. At laparotomy, 50 cm distal to the ligament of Treitz, a jejuno-jejunal intussusceptions was identified. We conducted a desinvagination Benin saw the character of the lesion on CT. The presence of irreversible ischemia in a small portion of the intussusceptum necessitated segmental resection and primary anastomosis (Figure 4). The postoperative period was uneventful and the patient was discharged on the sixth postoperative day. Gross examination of the respected specimen revealed a round tumor covered with mucosa measuring 6 cm. A microscopic examination revealed fat cells proliferating in the submucosal layer and confirmed the diagnosis of ileal lipoma (Figure 5). The histopathology report confirmed a 60-mm submucosal lipoma in the jejunum as a cause for a 30-cm jejuno-jejunal intussusceptions. There was no evidence of dysplasia or malignancy.
https://static-content.springer.com/image/art%3A10.1186%2F1749-7922-7-28/MediaObjects/13017_2012_Article_267_Fig1_HTML.jpg
Figure 1

Abdominal X-Ray. In favor of bowel obstruction.

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Figure 2

Abdominal computed tomography . Showing a fatty oval mass in the small intestine.

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Figure 3

Computed tomography scan of the abdomen without oral contrast . A longitudinal cut view of the intussusception shows the “sausage” shape.

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Figure 4

Intraoperative findings of the lipoma: A pedunculated lesion, measuring 60 mm, was the lead point of the intussusception.

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Figure 5

Histological findings of the tumor . A histopathologic examination of the tumor revealed fat cells proliferating in the submucosal layer.

Discussion

Intussusceptions in adulthood is unusual, with an incidence of approximately 2-3 cases per population of 1 000 000 per year[5]. The most common classification system divides intussusceptions into four categories: enteric, ileocolic, ileocaecal and colonic[14]. In adults, intussusceptions is more likely to present insidiously with vague abdominal symptoms and rarely presents with the classic triad of vomiting, abdominal pain and passage of blood per rectum, making diagnosis difficult[6]. Tumors of the small bowel account for only 1% to 2% of all gastrointestinal tumors, and benign tumors account for approximately 30% of all small-bowel tumors[7]. Lipomas are benign tumors of mesenchymal origin. They are the second most common benign tumors in the small intestine and account for 10% of all benign gastrointestinal tumors and 5% of all gastrointestinal tumors[1, 2, 5]. Gastrointestinal lipomas are most commonly located in the colon (65% to 75%), small bowel (20% to 25%) and occasionally in the foregut (< 5%)[8]. Fifty-one cases of adult intussusceptions induced by a lipoma, including our present case, have been reported in the English literature during the past decade (Table 1)[9]. Lipomas are largely asymptomatic. The majority of presenting features are either intestinal obstruction or hemorrhage[1, 2, 58]. Their usual location in the small intestine is ileum (50%) while jejunum is the least common. The peak age of incidence is in the 6th-7th decades of life and it appears that females are more prone to lipomas. Malignant degeneration has never been reported[5]. The clinical presentation is very non-specific which makes this a difficult condition to diagnose. According to the literature, only 32% to 50% of cases are diagnosed preoperatively, despite the evolution of imaging methods[911]. Abdominal pain, nausea, diarrhea and bleeding per rectum are the common symptoms. Rarely, this can present with acute intestinal obstruction. The classical triad of abdominal pain, sausage shaped palpable mass and passage of red current jelly stools seen in children is rarely seen in adults. Fewer than 20% of cases present acutely with complete bowel obstruction. A palpable abdominal mass is present in only 7% to 42% of cases[12, 13]. Lipomas can be diagnosed through conventional endoscopy, capsule endoscopy, barium studies and, most importantly, CT scan[14]. Ultrasound is usually the first modality to be recruited. However, it is operator-dependent and the presence of distended bowel decreases the ability to demonstrate the site of the obstruction. Computed tomography is the imaging method of choice for diagnosing intussusceptions. A submucosal lipoma can be diagnosed if a smooth well-circumscribed mass of fat density (-50 to -100 Hounsfield Units) is revealed within the lumen of the bowel or intussuscipiens. The sensitivity of CT scan to correctly diagnose intussusceptions has been reported from 71.4%-87.5% while its specificity in adults has been reported to be 100% as verified by the subsequent surgery[14, 15]. Capsule endoscopy and digital balloon endoscopy are newer means for diagnosing lipomas and are particularly helpful in cases involving small bowel lipomas[8]. Definitive surgical resection remains the recommended treatment for adult intussusceptions due to the large proportion of structural causes and the relatively high incidence of malignancy; however, the optimal surgical management remains controversial[1, 2, 6, 7, 9]. Some investigators have stated that small bowel intussusceptions should still be reduced only in patients in whom a definitive benign diagnosis has been made preoperatively, or in patients in whom resection may result in short gut syndrome[9]. The dangers of transperitoneal, vascular, and intraluminal seeding after exposing and handling friable and edematous malignant tissues has led many surgeons to advocate en bloc resection of the lesion. All surgeons agree, though, that reduction should not be attempted if there are signs of irreversible bowel ischemia, inflammation or when malignancy is being suspected[5, 16, 17]. The advantages of intraoperative reduction of the intussusceptions prior to resection, especially when the small bowel is affected, are that it may preserve a considerable length of bowel and thereby prevent development of short-bowel syndrome.
Table 1

The characteristics of the reported cases of adult intussusception induced by a lipoma

Case

Age

Gender

Diagnostic modality

Tumor location

Size (cm)

Reference

1

69

Male

US, CS

Descending colon

4

J Clin Ultrasound

2

42

Male

CS, BE, CT

Descending colon

4.5

Am Surg

3

39

Male

US, CT

Ileum

4

J Korean Med Sci

4

72

Male

EGD, US, CT

Stomach

10

Dig Surg

5

28

Male

CT

Jejunum

3

Ann R Coll Surg Engl

6

20

Female

CT

Ileum

18

Emerg Radiol

7

41

Male

CT

Ileum

ND

Australas Radiol

8

44

Female

CT, CS, ECS

Ileum

5

Abdom Imaging

9

51

Female

US, ECS, CT

Cecum

10

Rom J Gastroenterol

10

56

Male

US, CT

Ascending colon

6

J Laparoendosc Adv Surg Tech A

11

50

Male

ECS, CS, CT

Ascending colon

5

Pathol Int

12

72

Male

CT, EGD

Stomach

6

Can J Gastroenterol

13

55

Male

CT

Ileum

ND

Surg Today

14

63

Female

US, CT

Ileum

2.5

Surg Today

15

73

Female

ECS, MRI

Sigmoid colon

ND

Arch Surg

16

63

Male

CT

Ileum

3

JSLS

17

85

Male

US, CT

Jejunum

4

J Gastroenterol Hepatol

18

62

Male

CT, CS

Sigmoid colon

3.5

Dig Dis Sci

19

55

Female

CT

Transverse colon

12

Am Surg

20

31

Female

CT

Ascending colon

5

Can J Surg

21

47

Female

US, CT

Ileum

5

Ulus Travma Acil Cerrahi Derg

22

56

Female

US, CS, CT

Transverse colon

5

Ulus Travma Acil Cerrahi Derg

23

64

Male

CS, CT

Transverse colon

6

Clin Gastroenterol Hepatol

24

55

Male

CT, ECS

Jejunum

4

World J Gastroenterol

25

42

Male

US, CT

Ileum

3

Case Rep Gastroenterol

26

47

Female

CT

Ileum

3

J Laparoendosc Adv Surg Tech

27

47

Female

CT, CS, Enema

Ascending colon

5

Endoscopy

28

36

Male

CS, CT, ECS

Ileum

9

Cases J

29

36

Male

CT, ECS

Ileum

4

J Nippon Med Sch

30

82

Male

CS, CT

Sigmoid colon

8

Gastrointest Endosc

31

69

Male

CT, CS

Transverse colon

7

Dig Dis Sci

32

38

Female

CS, CT

Ileum

3.3

Clin Gastroenterol Hepatol

33

38

Female

US, CT, CS

Cecum

6

Emerg Radiol

34

45

Male

CT

Ileum

2.5

N Engl J Med

35

43

Female

CS, CT

Ascending colon

5

Rev Esp Enferm Dig

36

57

Female

CS, CT

Transverse colon

5.5

Rev Esp Enferm Dig

37

51

Male

US, CT, CS

Ileum

3

Gastroenterology

38

77

Male

CT

Cecum

3.5

JSLS

39

46

Male

CS, CT, ECS

Descending colon

6

Endoscopy

40

33

Male

CT, CS, BE

Ileum

4

Case Rep Gastroenterol

41

32

Female

CT

Ascending colon

5.8

Gastroenterology

42

49

Male

US, CT

Descending colon

5

Gastroenterology

43

53

Female

US, CS, ECS

Ascending colon

7

Medicina (Kaunas)

44

26

Female

CT

Ileum

ND

Am J Surg

45

51

Female

CT

Transverse colon

6.2

J Gastroenterol Hepatol

46

68

Male

CS

Jejunum

3.2

World J Gastroenterol

47

52

Female

CT

Ileum

3.2

J Med Case Reports

48

62

Female

US

Ileum

7

J Clin Ultrasound

49

65

Male

CT

Ileum

1.2

World J Gastrointest Surg

50

68

Female

US, CT, ECS

Ileum

1.5

Surg Today

51

35

Male

CT

jejunum

6

 

Conclusion

The lipoma is a rare benign tumor of the digestive tract. The diagnosis of intussusceptions in adults can be difficult because of atypical and episodic symptoms. A high level of clinical suspicion and an abdominal CT scan are most useful tools for making a timely diagnosis. Surgical resection remains the treatment of choice and produces an excellent prognosis.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images

Abbreviations

CT: 

Computed tomography

MRI: 

Magnetic resonance imaging

CS: 

Colonoscopy

ECS: 

Enema contrast study

EGD: 

Esophagogastroduodenoscopy

US: 

Ultrasonography

ND: 

Not described.

Declarations

Authors’ Affiliations

(1)
Surgery Department, University Hospital Hassan II
(2)
Department of pathology, University Hospital Hassan II

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Copyright

© Mouaqit et al.; licensee BioMed Central Ltd. 2012

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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