Midgut pain due to an intussuscepting terminal ileal lipoma: a case report

Journal of Medical Case Reports 2010, 4:51 doi:10.1186/1752-1947-4-51
Noormuhammad O Abbasakoor (abbasakn@tcd.ie)
Dara O Kavanagh (dara_kav@hotmail.com)
Diarmaid C Moran (morandiarmaid@gmail.com)
Barbara Ryan (abbasakn@tcd.ie)
Paul C Neary (paulcneary@msn.com)
ISSN 1752-1947
Article type Case report
Submission date 19 September 2009
Acceptance date 11 February 2010
Publication date 11 February 2010
Article URL http://www.jmedicalcasereports.com/content/4/1/51
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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.Midgut pain due to an intussuscepting terminal ileal lipoma: a case report

Noormuhammad O Abbasakoor
1
, Dara O Kavanagh1
, Diarmaid C Moran1
, Barbara Ryan2
,
Paul C Neary1*


Addresses:
1
Division of Colorectal Surgery, Adelaide and Meath Incorporating the
National Children’s Hospital, Tallaght, Dublin 24, Ireland.
2
Department of
Gastroenterology, Adelaide and Meath Incorporating the National Children’s Hospital,
Tallaght, Dublin 24, Ireland.

*Corresponding author

PCN: paulcneary@msn.com Abstract
Introduction
The occurrence of intussusception in adults is rare. The condition is found in 1 in 1300
abdominal operations and 1 in 100 patients operated for intestinal obstruction. The child
to adult ratio is 20:1.

Case presentation
A 52-year-old Irish Caucasian woman was investigated for a 3-month history of
intermittent episodes of colicky midgut pain and associated constipation. Ileocolonoscopy
revealed a pedunculated lesion in the terminal ileum prolapsing into the caecum.
Computed tomography confirmed a smooth-walled, nonobstructing, low density
intramural lesion in the terminal ileum with secondary intussusception. A laparoscopic
small bowel resection was performed. Histology revealed a large pedunculated polypoidal
mass measuring 4x2.5x2cm consistent with a submucosal lipoma. She had complete
resolution of her symptoms and remained well at 12-month follow-up.

Conclusion
This case highlights an unusual cause of incomplete small bowel obstruction successfully
treated through interdisciplinary cooperation. Ileal lipomas are not typically amenable to
endoscopic removal and require resection. This can be successfully achieved via a
laparoscopic approach with early restoration of premorbid functioning.







Introduction
Neoplasms of the small intestines are rare [1]. Gastrointestinal lipomas are benign
tumors that can occur in the small bowel but occur most commonly in the colon. The
majority are asymptomatic and are detected incidentally on abdominal imaging. Removal
is warranted if tissue diagnosis is deemed essential or if severe symptomatology, such as
pain or bleeding, exists [2].

We report a case of terminal ileal lipoma causing intermittent intussusception in a 52-
year-old woman. The lipoma was diagnosed at ileocolonoscopy and successfully removed
through laparoscopy. A review of the literature on small bowel intussception and
gastrointestinal (GI) lipomas is also presented in this report.

Case presentation

A 52-year-old Irish Caucasian woman presented with a three-month history of
intermittent central abdominal pain and constipation. She did not describe
gastrointestinal bleeding or weight loss. She previously underwent a transabdominal
hysterectomy for menorrhagia. Her physical examination was unremarkable. Initial
investigations, such as blood tests, abdomen ultrasound and gastroscopy were
unremarkable. Ileocolonoscopy revealed a pedunculated terminal ileal lesion prolapsing
into her caecum. Computed tomography (CT) of her abdomen and pelvis demonstrated a
smooth-walled, low-density, intramural lesion in the terminal ileum. It measured
3.2x1.6cm. The ileum at the proximal end of the lesion was mildly dilated with a
centrally placed narrowed channel of contrast, which was consistent with an
intussusception possibly secondary to an intramural lipoma. There was no evidence of
obstruction (Figure 1).

She underwent an elective laparoscopic small bowel resection and stapled functional
end-to-end anastomoses. On macroscopy the lesion appeared as a large pedunculated
polypoid mass measuring 4x2.5x2cm with focal mucosal ulceration (Figure 2). Microscopy revealed a submucosal lipoma with blunting of the overlying mucosal villi and
pyloric gland metaplasia. She made an uneventful recovery and was discharged home on
the fourth postoperative day. She returned to work on the 12th
postoperative day. She
remained free of symptoms at three-month follow-up.

Discussion

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. They are predominantly submucosal and
protrude into the lumen [2]. Occasionally, they arise in the serosa. Gastrointestinal
lipomas are most commonly located in the colon (65% to 75%, especially on the right
side), small bowel (20% to 25%), and occasionally in the foregut (<5%) [2]. Lipomas
are largely asymptomatic. Major presenting features are intestinal obstruction and
hemorrhage [3].

Intussusception in adults is a rare entity that it is generally caused by definable
intraluminal pathology [4]. Diagnosis can be challenging. Intussusception is classified
according to its gastrointestinal location: enteric, ileocaecal, or colonic [4]. In ileocaecal
intussusceptions, the ileocaecal valve acts as the lead point. The ileum
(‘intussusceptum’) telescopes into the colon (‘intussuscipiens’) through the ileocaecal
valve [5, 6]. Intussusception leads to the development of venous and lymphatic
congestion, which results in intestinal edema. If not treated promptly, the arterial blood
supply to the bowel will be compromised, thus leading to ischaemia, perforation and
peritonitis [4]. Only 5% of all intussusceptions occur in adults [7]. In 90% of these cases
a predisposing lesion is identified [7]. This is contrary to intussusception in the pediatric
population where an organic lesion is found in only 10% of documented cases [3]. In
adults, it is important to differentiate between small bowel and colonic intussusception.
In 63% of cases of small bowel intussusceptions, a benign underlying lesion can be found. Meanwhile, a malignant etiology has to be expected in 58% of cases of large
bowel intussusceptions [8].

Lipomas can be diagnosed through conventional endoscopy, capsule endoscopy, barium
studies and, most importantly, CT. Typical endoscopic features are smooth, yellowish
surface with pedunculated or sessile base, as seen in this case. Other endoscopic
characteristics are the ''cushion sign'' and ''naked fat sign” [2]. CT usually reveals a
smooth, well-demarcated sausage-shaped mass. It may also reveal associated
intussusception if present [5]. Capsule endoscopy and digital balloon endoscopy are
newer means for diagnosing lipomas and are particularly helpful in cases involving small
bowel lipomas [2]. Associated intussusception can be confirmed on contrast enema
(‘crescent sign’), CT and magnetic resonance imaging (MRI). Multislice CT facilitates the
assessment of vascular supply to the affected bowel loop in cases of intussusception
where impending ischemia is suspected [4].

The treatment for lipomas depends on the clinical manifestations. Indications for their
removal include intestinal obstruction, hemorrhage and malignant potential [4]. There is
a theoretical risk of sarcomatous change but this has rarely been documented in the
literature [1]. Endoscopic removal is possible but potentially complicated. In view of the
submucosal location, there is an inherent risk of perforation [9]. Furthermore, lipomas
have high water content, which means a large amount of cautery is necessary to achieve
effective hemostasis [9]. Surgery can be performed through laparoscopy or via an open
approach. The type of resection and anastomosis depends on the location, bowel wall
integrity, and vascular supply of the lipoma [6]. Elective laparoscopic resection of
lipomas is the treatment of choice with the concomitant benefits of laparoscopic surgery,
such as shorter duration of hospital stay, less postoperative pain, early restoration of
(GI) function and good cosmesis [6].

Conclusion In this case, we illustrate the importance of a thorough interdisciplinary evaluation of
patients with midgut abdominal pain. It highlights the diagnostic values of CT scanning
and completed ileocolonoscopy. Despite preoperative localization, laparoscopy facilitates
a thorough evaluation of the intraperitoneal contents and therapeutic resection of the
affected segment. This report confirms the recognized benefits of laparoscopic surgery
with associated early return to premorbid functioning. In patients with persistent
episodes of incomplete intestinal obstruction, atypical causes, such as the etiology we
describe here, should be considered.

Consent
Written informed consent was obtained from our patient for publication of this case
report and any accompanying images.

Competing interests
The authors declare they have no competing interests.

Authors’ contributions
NOA contributed in collecting the requisite literature and wrote the case report. DOK also
collected the requisite literature and reviewed the literature. DCM also contributed in
collecting the requisite literature. BR and PCN were involved in the diagnosis of our
patient. PCN also performed the surgery. All authors read and approved the final
manuscript. References
1. Rathore MA, Andrabi SI, Mansha M: Adult intussusception: a surgical
dilemma. J Ayub Med Coll Abbottabad 2006 Jul-Sep, 18(3):3-6.
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PK: Obscure gastrointestinal bleeding caused by small bowel lipoma.
Inter Med 2008, 47:1601-1603.
3. Balik AA, Ozturk G, Aydinli B, Alper F, Gumus H, Yildirgan MI, Basoglu M:
Intussusception in adults. Acta Chir Belg 2006 Jul-Aug, 106(4):409-412.
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Figure legends
Figure 1. Contrast-enhanced computed tomography scan of the abdomen demonstrates
a smooth-walled, low-density intramural lesion. It measures 3.2x1.6cm. The ileum at the proximal end of the lesion is mildly dilated with a centrally placed narrowed channel of
contrast consistent with an intussusception.

Figure 2. Macroscopic view of a large pedunculated polypoid mass arising from the
luminal surface of the ileal resection specimen. Appearances are consistent with a
lipoma.

Figure 1