Ileo-ileal intussusception in an adult by lipoma

Abstract

Introduction Though adult intussusception is rare, but it is a well-recognised condition in adults. In adults, intussusception is commonly associated with underlying pathology. While the condition is clinically non-specific, the intestinal obstruction is found to be a common presentation. Ileal lipoma demonstrates as an underlying pathological lead point is thus found to be a rare condition. In this case report, a case of ileo-ileal intussusception, with ileal lipoma demonstrating an underlying pathological lead point, in a 60-year-old female patient is reported. Case Report We present a case of a 60-yearold female patient with pain in her right lower abdomen and nausea that lasted for 2 days. Contrastenhanced computed tomography scan confirmed the diagnosis of intussusception in the patient. Ileal lipoma was the lead point for intussusception that was diagnosed at laparotomy, which is a surgical incision into the abdominal cavity. Conclusion The results show that intussusception in adult is a rare condition. Lipoma, which acts as an underlying pathological lead point, is rarely found. Introduction Intussusception is defined as the invagination of one portion of the bowel into an immediately adjacent portion; the proximal segment of the gastrointestinal tract, or the intussusceptum, is carried within the lumen of an adjacent segment known as the intussuscipiens1. Intussusceptions may be classified as ileocolic, ileocecal, colo-colic and ileo-ileal2. Adult intussusception is relatively a rare and is substantially a different clinical entity from paediatric intussusception3. Most adult intussusceptions are benign and represents 1% of all bowel obstructions, 5% of all intussusceptions and 0.003%–0.02% of all hospital admissions4,5. Adult patients mostly complain of obscure abdominal pain only6. In adults, there is a lack of classical triad of abdominal pain, palpable abdominal mass and passage of ‘red currant jelly’ stools, but these are commonly found in children7. Intestinal lipoma is an uncommon causation of adult intussusception and some lipoma may cause intussusception by acting as the lead point located in the ileum8,9. The diagnosis of intussusception is readily suggested because of its pathognomonic appearance on computed tomography10. This report discusses ileo-ileal intussusception in an adult by lipoma. Case Report We present a case of a 60-year-old female patient with pain in her right lower abdomen and nausea that lasted for 2 days. While the general physical examination was unremarkable, the systemic examination was found to be normal. A vague abdominal mass was palpable in the right lower abdomen as found in individual abdominal examination. There was a slight increase in bowel sounds. On digital rectal examination, the rectum was found to be empty with the presence of rectal ballooning. Plain X-ray abdomen findings showed multiple levels of air fluid. Ultrasound sonography abdomen scans revealed doughnut sign. Contrastenhanced computed tomography (CECT) scan of the abdomen, demonstrated a well-defined sausage shaped intraluminal mass in the terminal ileum, showing a target sign (Figure 1). Diagnosis of intussusception was performed. On exploratory laparotomy, an invagination of segment of ileum into distal segment of about 30 cm from the ileocaecal junction was present (Figure 2). Resection of involved segment was also performed. A polypoid mass, measuring 3 × 3 cm with gross appearance of lipoma, was found acting as a lead point (Figure 3). The diagnosis of lipoma was confirmed by histopathology. The post-operative period of the patient was found to be uneventful. Discussion Intussusception is a rare clinical entity in adults11. The mechanism of intussusception is unclear12. Male-to-female ratio is 1:1.3 and mean age of presentation is 54.4 years of adult intussusception13. The adult intussusceptions are classified in three steps with aetiology, namely benign, malignant or idiopathic14. Intussusception could be either idiopathic type or secondary type15. In idiopathic type, intussusception occurs without a lead point lesion. In secondary type intussusception, mostly organic lesions have been implicated16–19. The clinical presentation of an adult small bowel intussusception varies considerably in adults. In a study among 148 patients, the most common symptoms at presentation were abdominal pain (72%), nausea (49%), vomiting (36%) and approxi* Corresponding author Email: imtazwani@gmail.com 1 Department of General Surgery, Sher-iKashmir Institute of Medical Sciences, Srinagar, India 2 Department of General Surgery, Florence Hospital, Chanapora,Srinagar, India Su rg er y