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Ileo ileal Intussusception Secondary to Lipoma Literature Review

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Ileo ileal Intussusception Secondary to Lipoma Literature Review Powered By Docstoc
					Acta chir belg, 2007, 107, 60-63

Ileo-ileal Intussusception Secondary to a Lipoma : a Literature Review
T. L. Oyen, A. M. Wolthuis, T. Tollens, C. Aelvoet, J. P. Vanrijkel
Department of General Surgery and Traumatology, A.Z. Imelda, Bonheiden, Belgium.




Key words. Lipoma ; small bowel ; intussusception ; ileum ; invagination.

Abstract. Intussusception is rare in adults and it can be a challenge to diagnose on admission. Non-specific and vari-
able signs and symptoms, frequently only occurring episodically, may cause a considerable delay before treatment.
However, in 90% a predisposing organic cause can be found in adults.
A case is presented of small bowel intussusception secondary to a lipoma in a 54-year-old man in whom diagnosis was
suggested by CT-scan. The patient was treated with a laparoscopic-assisted reduction and extracorporeal partial small
bowel resection, followed by a latero-lateral anastomosis.
This case serves as the basis of a review of small bowel intussusception in adults secondary to lipomas. It focuses on
the rarity of the disease, but stresses the need for early referral and investigation in middle-aged patients with recurrent
abdominal symptoms.



Introduction                                                     and a regular pulse of 60/min. He was afebrile. Clinical
                                                                 examination revealed peri-umbilical tenderness with
Abdominal pain is a frequent problem in patients                 hyperperistalsis, with no sign of peritonism. Laboratory
referred to the emergency department. A diagnostic pit-          tests showed a CRP of 0.2 mg/dl (< 0.5 mg/dl) and a
fall is intussusception, because it only rarely occurs in        white blood cell count of 16,000/µl (3,900-10,600/µl).
adults. This contrasts with intestinal intussusception in        Abdominal X-ray showed a mesogastric sentinel loop.
children, which is a well described and frequently               Computed tomography (CT) scan showed ileo-ileal
reported entity (1-3). Intussusception is defined as the         small bowel intussusception with an intraluminal soft
prolapse of one segment of the intestines into a distal          tissue mass with negative attenuation numbers sugges-
segment. Because clinical examination and investigation          tive of a lipoma (Fig. 1).
is often inconclusive, many adult patients are discharged           Based on this observation, a laparoscopic exploration
with the diagnosis of ‘irritable bowel syndrome’. In             was performed. During this procedure the diagnosis of
almost 50% of cases, the diagnosis of intussusception in         small bowel intussusception was confirmed and an
adults is only made during surgery (3-5). Medical atten-         extracorporeal partial small bowel resection with latero-
tion is necessary because malignant aetiology can be             lateral mechanic anastomosis was carried out. Histolo-
present (1-3).                                                   gical analysis of the specimen showed an ulcerated
   A review of the literature on small bowel intussus-           lipoma without evidence of malignancy. The post-
ception and gastro-intestinal lipomas is made, based on          operative course was uneventful and the patient was
a well illustrated case of ileo-ileal intussusception sec-       discharged after one week.
ondary to a lipoma.
                                                                 Discussion
Case Report
                                                                 Intussusception
A 54-year-old man was admitted to the emergency
department with acute abdominal pain. After a previous           Intussusception is classified according to its gastro-
episode of acute abdominal pain the diagnosis of ‘irrita-        intestinal location : enteric, ileocaecal, and colonic (1-3,
ble bowel syndrome’ with normal colonoscopy had been             6). However, it is difficult to distinguish the different
suggested. Four hours before referral, the patient had           subtypes clinically.
suffered from severe abdominal pain, colicky in nature,             Ileocaecal intussusceptions use the ileocaecal valve as
associated with nausea and vomiting. The pain was                the lead point : the ileum telescopes into the colon
localized centrally and did not respond to analgesia and         through the ileocaecal valve (1). Intussusception leads to
spasmolytics. On admission the patient was haemody-              the development of venous and lymphatic congestion,
namically stable with a blood pressure of 145/80 mmHg            resulting in intestinal oedema. If not treated immediately,
Review of Small Bowel Intussusception Secondary to a Lipoma                                                               61

                                                                 intussusception. Lymphoma, lymphosarcoma and
                                                                 leiomyosarcoma have also been reported as tumoral
                                                                 mass inducing intestinal invagination (3). Benign
                                                                 lesions provoking large bowel intussusception include :
                                                                 lipoma, leiomyoma, adenomatous polyp or endometrio-
                                                                 sis and up to 13% of the colonic intussusception cases
                                                                 remain unexplained (2). Malignant causes of enteric
                                                                 intussusceptions are predominantly metastases ; only
                                                                 rarely is a primary small bowel malignant tumour
                                                                 reported. Non-malignant lesions include benign
                                                                 tumours, Meckel’s diverticulum, lymphoid hyperplasia,
                                                                 adhesions and trauma. About 20% of cases are idiopath-
                                                                 ic (2, 3, 14).

                                                                 Radiology
                                                                 CT-scan has become the key-modality for the diagnosis
                           Fig. 1                                of intussusception, especially with multislice CT and the
Abdominal CT-scan. The arrow shows ileo-ileal small bowel        availability of multiplanar reformatting. Compared to a
intussusception with a soft tissue mass lesion with negative     barium enema, upper gastro-intestinal (GI)-series, ultra-
attenuation numbers consistent with a lipoma.
                                                                 sound and plain films, CT-scan is the most sensitive
                                                                 test (3, 10, 12, 14, 15). The features of intussusception
                                                                 on CT-scan are characteristic : a soft tissue mass con-
the arterial blood supply to the bowel will be jeopar-           taining an outer intussusceptions and an inner intussus-
dized. This can lead to ischaemia, perforation and peri-         ceptum (16). When a malignant lesion is suspected, a
tonitis, resulting in a potentially lethal condition (1, 2, 4,   CT-scan is also useful for staging. It can identify bowel
7).                                                              dilatation, free liquid, metastases or lymphadenopa-
    The most common presenting sign and symptom of               thy (10, 11). CT also correlates with the pathological
an adult patient with intussusception is colicky abdomi-         stages of oedema, ischemia and necrosis (17). Yet, there
nal pain (71% to 90% of patients) (1, 2). Nausea and             are some disadvantages : the fact that it is a static inves-
vomiting, bleeding, diarrhoea, constipation, or a change         tigation, the level of radiation dose, and the need for
in bowel habits are other non-specific findings at the           contrast enhancement.
time of presentation. Palpation of an abdominal mass                Abdominal ultrasound is a generally available tech-
during clinical examination is only reported in less than        nique in an emergency setting. In the hands of skilled
50% of patients (8, 9). Clinically, intussusception pre-         and experienced sonographers it approaches the sensi-
sents either as acute pathology with signs and symptoms          tivity and specificity of CT, allowing a correct diagnosis
of abdominal obstruction, depending on the site of intus-        before surgery. Obesity and distended bowel loops
susception, or as a more chronic pattern with recurrent          decrease image quality (1, 2, 10).
abdominal pain (1-3, 10). This pain is characterised as             Conventional abdominal radiography may show a
recurrent and colicky. It can be explained by transient          dilated bowel loop. A barium enema is useful in colonic
intussusception and self-reduction of the affected               and ileocolic forms of intestinal intussusception, in find-
bowel (1, 2, 11). Usually, the duration of symptoms is           ing the location and a possible cause and can be thera-
longer in benign and enteric lesions compared to malig-          peutic in children (3, 4, 10, 14, 16). A sudden beak-like
nant and colonic lesions (1, 12).                                change from a proximally dilated bowel to a normal cal-
    Only 5% of all intussusceptions occur in adults (2, 8,       iber, seen on upper GI-series, is a characteristic finding
9, 13). In 90% of cases a predisposing lesion can be             for intussusception (2, 18). Colonoscopy or flexible sig-
found. This is contrary to intussusception in the paedi-         moidoscopy can be successfully used for reduction of a
atric population : an organic lesion is found in only 10%        colonic intussusception (1, 2, 19).
of the cases (2, 13). In adults, it is important to differen-       Diagnostic accuracy is essential to avoid unnecessary
tiate between small bowel and colonic intussusception :          surgery, to avoid surgical delay and to target surgery. A
in 63% of cases of small bowel intussusceptions a                correct diagnostic algorithm, when intussusception is
benign underlying lesion can be found, whereas in 58%            suspected, should be to obtain an abdominal ultrasound
of cases of large bowel intussusceptions a malignant             or a CT-scan. A CT-scan is more appropriate in colonic
aetiology has to be expected (2). Colon adenocarcinoma           intussusception because of a higher possibility of malig-
is the most important cause of malignant large bowel             nant disease.
62                                                                                                           T. L. Oyen et al.

Lipoma                                                       bloc resection the best option, because of the lower risk
                                                             of perforation or spillage. On the other hand we can
A lipoma of the gastro-intestinal system, found post
                                                             defend reduction followed by an elective resection in
mortem in 0.2%, is a benign tumour composed of
                                                             cases of small bowel invagination. Reduction, managed
mature lipocytes (20, 21). It can be found anywhere in
                                                             by distal milking and proximal pulling, is followed by
the alimentary tract, most often in the colon (70%) (21).
                                                             extracorporeal removal of the small intestine tumour, in
Only 20 to 25% are found in the small bowel (21). Small
                                                             this case a submucosal lipoma. Thus, in our opinion,
bowel lipomas are usually solitary but may occasionally
                                                             laparoscopy is a safe alternative to the surgical treatment
be multiple (22). Duodenal lipomas are less common
                                                             of small bowel intussusception if the CT-scan suggests a
than ileal or jejunal localizations. Most lipomas are sub-
                                                             tumour which appears benign.
mucosal (90-95%) and asymptomatic, until they become
larger than 1 or 2 cm (20, 21). When larger than 4 cm,
                                                             Conclusion
75% of the submucosal lipomas are symptomatic (8, 21,
23, 24). The most frequent presenting symptoms of lipo-
                                                             This observation illustrates all aspects of small bowel
mas are haemorrhage, melaena, obstruction, abdominal
                                                             intussusception secondary to a lipoma. It illustrated the
cramps, diarrhoea or constipation and intussuscep-
                                                             importance of a diagnostic CT-scan followed by an
tion (22, 25). If a segment of the alimentary tract with a
                                                             exploratory laparoscopy. As shown in other cases, diag-
lipoma (intussusceptum) enters another part (intussus-
                                                             nosis of intussusception can be delayed due to non-spe-
ceptions), intestinal invagination occurs. Subserosal
                                                             cific abdominal symptoms (31, 32). Therefore, in mid-
lipomas of the small bowel (5-10%) harbour, along with
                                                             dle-aged patients presenting with recurrent abdominal
the risk of invagination, the possibility of strangula-
                                                             symptoms, one should consider more unusual causes, as
tion (22). Because of the slow growth of lipomas, most
                                                             described above. We believe that for this pathology
patients are 50 to 60 years old when they become symp-
                                                             laparoscopic evaluation and resection is the treatment of
tomatic, as in this case, but no important gender differ-
                                                             choice and we stress the need for a minimally invasive
ence is reported (22). No malignant transformation of
                                                             procedure in this often benign pathology.
lipomas has been reported in the literature and after
resection, no recurrence is to be expected (3, 26).
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