Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 2001  |  Volume : 7  |  Issue : 1  |  Page : 34-36
Endoscopic management of a large sigmoid lipoma with intussusception in a young woman: Case report


Department of Surgery, King Khalid University Hospital, Riyadh, Saudi Arabia

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Date of Submission28-Jul-1999
Date of Acceptance25-Nov-1999
 

How to cite this article:
Abdulkarim AA. Endoscopic management of a large sigmoid lipoma with intussusception in a young woman: Case report. Saudi J Gastroenterol 2001;7:34-6

How to cite this URL:
Abdulkarim AA. Endoscopic management of a large sigmoid lipoma with intussusception in a young woman: Case report. Saudi J Gastroenterol [serial online] 2001 [cited 2019 Jul 23];7:34-6. Available from: http://www.saudijgastro.com/text.asp?2001/7/1/34/33412


Colonic Intussusception occurs more frequently in pediatric age and most often it is idiopathic. In contrast intussusception in adults is rare and accounts to less than 16% of cases [1],[2] . In adults the underlying etiology has been identified in more than 80% of cases, where malignant and benign neoplasm account to 75% [3] . Colonic lipomas may induce intussusception. They are rare, usually small and allocated to the right colon. Larger pedunculated lipomas have been associated with intermittent colonic Intussusception [4].

We report a case intussusception in a young woman induced by a large sigmoid lipoma, which was managed successfully by endoscopic reduction and removal of the lipoma.


   Case Report Top


A 35-years old female, para 6+0, 20 days post normal spontaneous vaginal delivery, who underwent cesarean section three years prior to her admission presented to the emergency department, King Khalid University Hospital, Riyadh with intermittent, colicky left sided abdominal pain of two weeks duration. The pain was associated with occasional nausea, vomiting and loose motion with hematochezia.

Abdominal examination revealed a scar of previous cesarean section. The abdomen was soft and lax. A lOx4cm large, sausage-shaped tender mass was palpated at the left iliac fossa. On digital examination the rectum was empty, no blood or mucus noted. General and systematic examination was unremarkable.

Hematological and biochemical investigations were normal. Erect and supine abdominal radiography showed features of large bowel obstruction. A limited gastrographin enema revealed a well-defined mass occluding the bowel lumen at the mid sigmoid colon highly suggestive of intussusception induced by a colonic polyp [Figure - 1]. Also, abdominal ultrasonography supported the diagnosis and demonstrated a homogenous, oval, well-defined, 5cm large mass within the sigmoid colon along with proximal features of a linear mass [Figure - 2].

Urgent colonoscopy showed a large, oval, polypoid mass with a smooth surface and shiny mucosa at 30 cm above the anal verge obstructing the lumen and forming the lead point of intussusception. A successful endoscopic reduction and removal of the mass using a large polyrectomy. snare was achieved [Figure - 3].

The gross pathological examination revealed a 7.5x4.5cm, large Lipoma with ulcerated hemorrhagic surface. The histopathological section showed lobules of mature lipocytes separated by thin fibrovascular connective tissue septa [Figure - 4]. The post endoscopic treatment period was uneventful. The patient was discharged on the third day after she tolerated normal diet and opened her bowel normally. Barium double contrast and colonoscopy performed two months later were normal. The patient visited regularly the outpatient clinic for one year and she remained asymptomatic over the whole period.


   Discussion Top


Colonic limpoma are rare with a reported autopsy incidence of 0.2% [5] . They are commonly located at the right colon in particular the ceum[4] . Majority occurs in elderly [3] and usually does not produce symptoms unless they exceed 4 diameter [5]. Our patient presented with intermittent colicky, abdominal pain, vomiting, loose motion and hematocheazia due to sigmoid intussusception induced by a large Limpoma. Intussusception in adults has been in the majority of cases due to malignant or benign neoplasm [3] . Limpomas are known to induce intussusception [4],[6],[7],[8],[9],[10] . Imaging techniques have been utilized to diagnose intussusception. While plain abdominal radiography has been non-specific, barium enema has diagnosed intussusception, mass or obstruction in 95% of cases [3] nowadays abdominal ultrasonography and computed tomgraphy have been more commonly utilized for a definitive diagnosis of intussusception. Abdominal ultrasonography reveals a target-like appearance in a cross-section and parallel hypoechoic alternating with hyperchoic lines in the longitudinal axis [8],[11] . Computed tomgraphy reveals thickening of the wall with a mass with fat density [12] . Alteration of fat density may occur as a result of fat necrosis due to intussusception [13] . In our patient and the plain film demonstrated evidence of large bowel obstruction. Water soluble contrast and abdominal ultrasonography were diagnostic for intussusception. Computed tomgraphy was not performed. In a series, primary colonic cancer has contributed to two thirds of colonic intussusception in adults. Therefore, hemicolectomy without reduction has been advocated. In contrast careful endoscopic search for cancer in patients with sigmoidorectal cancer is mandatory [3] . Recently, laparoscopic hemicolectomy has been recommended for intussusception caused by benign colorectal pathology such as lipoma[14].

Our patient was prepared for emergency surgical management immediately after endoscopic evaluation. During endoscopy an agreement between the educated patient, her brother, a consultant pediatrician, the surgeon and the gastroenterologist was made to remove the polypoid mass endoscopically taking the risk of perforation and bleeding in consideration.

The post endoscopic treatment was uneventful. We are not aware of endoscopic removal of Lipoma inducing intussusception. Although, it is not a standard management, hemicolectomy was avoided in this young patient.


   Acknowledgment Top


The author is grateful for Dr. M. Al-Saleh, Associate Prof. of surgery, Prof. D. Makanjuola, Prof. of radiology, Dr. A. Al-Rikabi Associate Prof. of pathology, Prof. M. Al-Sohaibani, Prof. of pathology and Prof. I Al- Mofleh, Prof. of gastroenterology for their suggestion and contributions and Hasim S. Mammah for excellent secretarial support.[14]

 
   References Top

1.Agha FP. Intussusception in adults. Am J Radiol 1986; 146: 527-31.  Back to cited text no. 1    
2.Lundby CM, Pahle E. Ultrasonic Diagnosis of colonic invagination. Ugeskr Laeger 1991;153: 121-2.  Back to cited text no. 2  [PUBMED]  
3.Nagorney DM, Sarr MG, Mcllrath DC. Surgical management of Intussusception in the adult. Ann Surg. 1981;193: 230-6.  Back to cited text no. 3    
4.Chan KC, Lin NH, Lien HC, Chan SL, Yu SC. Intermittent intussusception caused by colonic limpoma. J Formos Med Assoc 1998; 97:63-5.  Back to cited text no. 4  [PUBMED]  
5.Ho KJ, Shin MS, Tishler JM. Compute tomographic distinction of submucosal lipoma and adenamatous polyp of the colon. Gastrointest Radiol 1984;9:77-80.  Back to cited text no. 5  [PUBMED]  
6.Godron RS, O' Dell KB, Namon AJ, Becker LB. Intussusception in the adult-a rare disease, J. Emerg Med 1991;9:337-42.  Back to cited text no. 6    
7.Zeebregts CJAM, Geraeds AAM, Blaauwgeers JLG, Hoitsma HFW. Intussusception of the Sigmoid colon because of an intramascular lipoma. Dis Colon Rectum 1995;38:891-2.  Back to cited text no. 7    
8.Wulff C, Jespersen N. Colo-colonic intussusception caused by lipoma. Case reports. Acta Radiol 1995;36: 478-80.  Back to cited text no. 8    
9.Alponat A, Kok KY, Gob PM, Ngoi SS. Intermittent subacute intestinal obstruction due to a giant lipoma of the colon: a case report. Am Surg. 1996;62:918-21.  Back to cited text no. 9    
10.Kabaalioglu A, Gelen T, Aktan S, Kesici A, Bircan O, Luleci E. Acute colonic obstruction caused by intussusception and extrusion of a sigmoid lipoma through the anus sfter barium enema. Abdom imaging; 1997;22:389-91.  Back to cited text no. 10    
11.Rejnen HAM, Jooston HJM, DE Boer HHM. Diagnosis and treatment of adults intussusception. Am J Surg 1989; 158:258  Back to cited text no. 11    
12.Logrian JG, Dubrow RA. The computed tomographic appearances and clinical significance of intussusception in adults with malignant neoplasm Br J Radiol 1990;63:257-62.  Back to cited text no. 12    
13.Buetow PC, Buck JL, Can NJ, Pantongrag-Brown L, Ros PR, Cruess DF. Intussuscepted colonic lipoma: Loss of fat attenuation on CT with pathologic correlation in 10 cases. Abdom imaging 1996; 21:153-6.  Back to cited text no. 13    
14.Hackam DJ, Saibil F, Wilson S, Litwin D. Larascopic management of intussusception caused by colonic lipomata: a case report and review of literature. Surg Laparosc Endosc 1996; 6:155-9.  Back to cited text no. 14  [PUBMED]  

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Correspondence Address:
Amal Abdullah Abdulkarim
Senior registrar, King Khalid University Hospital, P. 0. Box 2925 Riyadh 11461
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19861764

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  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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