Skip to main content
main-content

01.12.2012 | Review | Ausgabe 1/2012 Open Access

World Journal of Emergency Surgery 1/2012

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

Zeitschrift:
World Journal of Emergency Surgery > Ausgabe 1/2012
Autoren:
Ouadii Mouaqit, Hafid Hasnai, Leila Chbani, Bachir Benjelloun, Hicham El Bouhaddouti, Karim Ibn el Majdoub, Imane Toughrai, Said Ait Laalim, Abdelmalek Oussaden, Khalid Maazaz, Afaf Amarti, Khalid Ait Taleb
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1749-7922-7-28) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

All of the authors were involved in the preparation of this manuscript. OM performed the operation and revised the manuscript. HH was an assistant surgeon and made substantial contributions to conception and design. LC described histological finding and was involved in drafting the manuscript. All authors read and approved the final manuscript.
Abbreviations
CT
Computed tomography
MRI
Magnetic resonance imaging
CS
Colonoscopy
ECS
Enema contrast study
EGD
Esophagogastroduodenoscopy
US
Ultrasonography
ND
Not described.

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.

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
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.

Authors’ original submitted files for images

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

All of the authors were involved in the preparation of this manuscript. OM performed the operation and revised the manuscript. HH was an assistant surgeon and made substantial contributions to conception and design. LC described histological finding and was involved in drafting the manuscript. All authors read and approved the final manuscript.
Zusatzmaterial
Literatur
Über diesen Artikel

Weitere Artikel der Ausgabe 1/2012

World Journal of Emergency Surgery 1/2012 Zur Ausgabe