Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 1999  |  Volume : 5  |  Issue : 3  |  Page : 146-147
Submucosal lipoma causing an unusual presentation of intussusception


Department of Surgery, College of Medicine, King Khalid University, Abha, Saudi Arabia

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Date of Submission28-Nov-1998
Date of Acceptance04-Apr-1999
 

How to cite this article:
Al Shehri MY. Submucosal lipoma causing an unusual presentation of intussusception. Saudi J Gastroenterol 1999;5:146-7

How to cite this URL:
Al Shehri MY. Submucosal lipoma causing an unusual presentation of intussusception. Saudi J Gastroenterol [serial online] 1999 [cited 2020 Jan 25];5:146-7. Available from: http://www.saudijgastro.com/text.asp?1999/5/3/146/33536


Colon intussusception in adults is not common [1] . Complete intussusception through the anus is even less common [2],[3] . In this paper a case of complete colon intussusception caused by a large lipoma in the colon, with a unique management problem is presented. A line of surgical approach for such presentation is suggested.


   Case Report Top


A 75-year-old Saudi male presented, to the emergency department, with a protruding mass through the anal canal. This patient reported an attack of lower abdominal pain 24 hours prior to presentation. The severity of the pain increased with time. He then noticed the protrusion of a large mass through the anal canal. This was accompanied by some bleeding and mucous discharge. He reported a similar attack of lower abdominal pain, 2 years previously that continued for a few hours and resolved spontaneously. There were no other significant findings in his present history. He was a diabetic on oral hypoglycemic medications and apart from that, was enjoying a perfect health. On examination, he was a thin healthy looking man. He was psychologically distressed, but with stable vital signs. His abdomen was soft but there was a palpable mass in the area of the sigmoid colon. Investigations revealed hemoglobin of 11.5 gm/dl, white blood cells of 5.6xl0 9 /L and normal electrolytes. Abdominal ultrasound revealed the presence of a mass effect in the descending sigmoid colon. Barium enema under low pressure revealed a hold-up of the barium at the splenic flexure area with an inter-luminal mass through the distal colon. The patient was then taken to the operating room, and under general anesthesia examined in the lithotomy position. There was a large mass, about 15 cm in diameter protruding through the anal canal [Figure - 1]. This mass could not be reduced due to its large size. Laparotomy was then performed through a midline incision. The transverse colon was found to be completely intussuscepting down to the anal canal. The mass was attached to the middle of the transverse colon and was the leading point of the intussusception. Because of the inability to reduce this large mass to facilitate resection of the colon, the mass was excised outside the anal canal. The stump was transfixed with 0 silk suture and the intussusception was then reduced. Resection of the transverse colon was then performed and primary anastomosis in an end-to-end fashion was made. The patient had an en eventful recovery. He was seen in perfect health in the outpatient department one year later. The histo-pathology report showed that this was a submucosal lipoma originating from the mid­transverse colon.


   Discussion Top


Colo-colic intussusception in adults is not common. Only 24 cases of intussusception originating in the colon were reported in the Mayo clinic over a period of 23 years [1] . Complete protrusion of the intussusception through the anus is rare [2],[3] . Neoplasms are usually responsible for the majority of adult intussusception and two-thirds of these are usually malignant [1],[4] .

Colonic lipomas are uncommon. They are usually submucosal, as in our case and the right colon is most frequently affected [5] . Intussusception of the colon because of lipomas has been reported [6],[7],[8] . Only one was found on Medline search that reported a case of sigmoid lipoma that intussuscepted through the anal canal after barium enema, causing acute colonic obstruction [8] .

Few points are interesting in the case. Firstly, this big anal protrusion caused a significant amount of distress to the patient and his family. The medical staff, particularly in the emergency department need to be aware of this disease entity to be able to organize a treatment plan. Secondly, the diagnosis may be confused with a large rectal polyp and the shape of the intussusceptum may be confused with a long stalk. Cutting of this would have led to colon perforation because there was no stalk at all. Thirdly, reduction of the mass was not possible because of its large size and the associated edema. This constitutes a management problem. Therefore, we recommend treating such patients along this following plan. The patient should be taken to the operating room and under general endo-tracheal anesthesia put in the lithotomy position. Both the abdomen and perineal areas are prepared and draped. Operative precautions for malignancy should be taken since 63% of colo-colic intussusception in some studies has been shown to be caused by malignancy [1] . The laparotomy should be performed first, the colon examined and the area of the intussusception identified. Then the perineal part is tackled. The tumour is excised and the intussusceptum is transfixed. Precautions against tumor cells dissemination, by coagulation or the application of antiseptic material are applied to the transfixed area [9] . The abdominal part is then completed; the intussusception is reduced and the colon is resected in the usual fashion.

 
   References Top

1.Nagorney DM, Sarr MG, Mcllrath DC. Surgical management of intussusception in the adult. Ann Surg 1981;193:230-6.  Back to cited text no. 1    
2.Elebute EA, Adesola AAO. Intussusception in Western Nigeria. Br J Surg 1964;51:440-4.  Back to cited text no. 2    
3.Ho L, Roseman LD. Complete invagination of the vermiform appendix with villous adenoma, intussuscepting to the splenic flexure of the colon. Surgery 1975;77:505-6.  Back to cited text no. 3    
4.Cotlar AM, Cohn Jr. Intussusception in adults. Am J Surg 1961;101:114-20.  Back to cited text no. 4    
5.Hancock BJ, Vajener A. Lipomas of the colon: A clinicopathologic review. Can J Surg 1988;3L178-81.  Back to cited text no. 5    
6.Zeebregts CJ, Gerraedts AA, Blaauwgeers JL, Hoitsma HE Intussusception of the sigmoid colon because of an intramuscular lipoma. Report of a case. Dis Colon Rectum 1995;38:891-2.  Back to cited text no. 6    
7.Buetow PC, Buck JL, Carr NJ, Pantongrag-Brown L, Ros PR and Cruess DF. Intussuscepted colonic lipomas: Loss of fat attenuation of CT with pathologic correlation in 10 cases. Abdom Imaging 1996;21:153-6.  Back to cited text no. 7    
8.Kabaalioglu A, Gelen T, Aktan S, Kesici A, Bircan 0 and Luleci E. Acute colonic obstruction caused by intussusception and extrusion of a sigmoid lipoma through the anus after barium enema. Abdom Imaging 1997;22:389-91.  Back to cited text no. 8    
9.Basha G, Penninckx T. Exfoliated tumour cells and locally recurrent colorectal cancer. World J Surg 1998;22:55-60.  Back to cited text no. 9    

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Correspondence Address:
Mohammad Yahya Al Shehri
Department of Surgery, College of Medicine, King Khalid University, P.O. Box 641, Abha
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864741

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