Although intussusception is generally discussed in the context of children, adult intussusception is an identified diagnosis accounting for 5% of all intussusceptions [1]. Intussusception is identified when the proximal segment of bowel called the intussusceptum, telescopes into the lumen of the adjacent distal segment, the intussuscipiens. Any lesion in the bowel wall or an irritant within the bowel lumen could change the normal peristaltic activity and thus can start the invagination of bowel leading to intussusception. In the case of adult intussusception a malignant tumor of the bowel acting as the apex of intussusception is always suspected; however rarely, a benign bowel lesion is confirmed to be the underlying cause [2]. In this case, we report a case of adult intussusception in a young woman caused by a colonic lipoma.

A 36-year-old Hispanic woman presented with intermittent pain in her left lower abdomen for seven months. The pain was associated with loss of appetite, abdominal distension, and diarrhea. She had no previous illnesses or relevant family history. On physical examination her abdomen was soft and she had tenderness in the left iliac region. Bowel sounds were normal and rectal examination revealed an empty rectum with no sign of bleeding. All routine investigations, including amylase and thyroid function tests, were normal. A computed tomography (CT) scan showed findings of a long segment intussusception of the descending colon into the sigmoid colon with a 3.4 cm lipoma at the distal aspect (Figure 1) (Figure 2) (Figure 3). A Gastrografin follow-through showed complete obstruction to the retrograde flow of contrast around the level of the sigmoid colon (Figure 4). Attempts to reduce the intussusception failed with Gastrografin enema and therefore a sigmoid colectomy was scheduled.

The patient underwent surgery revealing an elongated mass in the sigmoid colon, which was acting as the lead point for intussusception. Sigmoid colectomy with anastomosis was performed. The resected specimen was a yellowish, oval, and broader-based homogeneous tumor, 4x4x3 cm in size, rising from the submucosal layer of the colonic wall. Microscopic examination of the specimen confirmed the diagnosis of a submucosal lipoma composed of mature fat cells with no focal ulceration, and no necrosis of the overlying colonic mucosa. The patient was discharged home five days postoperatively.

Intestinal lipomatosis presenting as intussusception is rare with only 46 cases reported in English literature over the last 45 years [3]. In contrast to intussusceptions in children, a demonstrable etiology is found in 70–90% of cases in the adult population [4]. In adults 2/3 of colonic intussusception has resulted from primary adenocarcinoma therefore unconfirmed etiology before operation must be interpreted as cancer [5].

A lipoma of the large intestine is a benign non-epithelial tumor with a reported incidence ranging between 0.2% and 4.4%, representing the second most common benign tumor of the gastrointestinal tract after hyperplastic polyps [6]. Colonic lipomas are generally solitary with only around 6% of cases presenting with multiple colonic lipomas [6]. In approximately 90% of cases the lipoma arises from the submucosa with only 10% being subserosal, extending into the muscularis propria [7]. The most common location for a solitary colonic lipoma is the ascending colon (45.5%), followed by the sigmoid colon (30.3%), descending colon (15.2%), and transverse colon (9.1%) [6]. Paskauskas et al., found that in their analysis of 31 patients with colonic intussusception by a colonic lipoma only 3/31 (8%) of patients had a similar lipoma in the descending colon intussuscepting into the sigmoid colon like our patient [3].

Not all patients with a colonic lipoma develop symptoms with only 20–25% of patients developing symptoms such as intussusception [3]. A lipoma larger than 4 cm is considered giant and produces symptoms in 75% of cases [3]. The clinical presentation of intussusception by colonic lipoma varies considerably in adults and includes abdominal pain (67–100%), diarrhea (32%), constipation (13%), hemorrhage (22–29%), and vomiting (11–24%) [3].

Intraoperative pathology is the most important examination for cases of intussusception, which directs definitive surgical management. Computerized axial tomography scan (CT) and magnetic resonance imaging (MRI) are the preferred methods of diagnosis as their imaging characteristics are relatively typical for adipose tissue and they provide a rapid diagnosis [8]. The sensitivity for diagnosis of colonic intussusception by CT was found to vary between 58–100% [9]. If the preoperative diagnosis of colon lipoma can be made correctly, the extent of surgery may be appropriately limited [10].

In conclusion, definitive treatment for adult intussusception caused by a colonic lipoma should be established on an individual basis.

We are thankful to Dr. Gurumurthy: Spartan Health Sciences University: School of Medicine.

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