Adult ileocolic intussusception secondary to asubmucosal cecal lipomaC. Triantopoulou,1 A. Vassilaki,2 D. Filippou,3 S. Velonakis,2 C. Dervenis,3

E. Koulentianos2

1Department of Computed Tomography, Konstantopoulion “Agia Olga” General Hospital, Pindos Square, Koritsas Street, 15452 P.Psyhiko, Athens, Greece2Department of Radiology, Konstantopoulion “Agia Olga” General Hospital, Pindos Square, Koritsas Street, 15452 P. Psyhiko, Athens,Greece31st Department of Surgery, Konstantopoulion “Agia Olga” General Hospital, Pindos Square, Koritsas Street, 15452 P. Psyhiko,Athens, Greece

Abstract

Intussusception is a relatively common cause of intestinalobstruction in children but a rare clinical entity in adults,representing fewer than 1% of intestinal obstructions in thispatient population. We present a rare case of a 44-year-oldfemale patient with intestinal obstruction due to ileocolic andcolocolonic intussusception secondary to an intramural cecallipoma. Diagnosis was made by barium enema and abdom-inal computed tomography and was confirmed by colonos-copy. After failure of conservative treatment, the patientunderwent surgery.

Key words: Intussusception—Cecal lipoma—Abdominalcomputed tomography—Barium enema

Intussusception can be described as the telescoping of onesegment of the bowel into an adjacent one. It is uncommonin adults (6% of all intussusceptions). However, unlike pe-diatric cases, there is often a leading point or a specific causein 80% of adult cases.

Plain films of the abdomen may show a soft tissue massor a bowel obstruction. In 25% of abdominal plain radio-graphs, no pathologic findings are present. Barium studiescan demonstrates the classic “coil-spring” appearance at thepoint of intussusception. Cross-sectional imaging modalitiessuch as ultrasound and computed tomography (CT) mayshow a “donut/target/bull’s eye” sign or a “pseudo-kidney”sign.

We present a rare case of colonic lipoma-induced intus-susception diagnosed by CT.

Case reportA 44-year-old female patient with no previous medical his-tory presented in our emergency department complainingabout abdominal pain with sudden onset and vomiting. Onphysical examination, the abdomen was distended, bowelmovements were diminished, and a sausage-like palpablemass was found in the right lower quadrant.

Abdominal CT showed ileocecal intussusception and amass-like lesion with density values consistent with fattytissue at the end of the involved bowel segment (Fig. 1).Differential diagnosis included entrapped mesentery or alipoma as the leading cause. Barium enema then demon-strated a large filing defect in the hepatic flexure (Fig. 2).

Colonoscopy proved the presence of a large intramuralsubmucosal tumor in the cecum incompletely obstructing theintestinal lumen and causing intussusception.

Due to the patient’s clinical improvement, conservativetreatment was chosen. Four days later, the patient experi-enced colicky pain, and abdominal radiography showedcomplete intestinal obstruction.

Intraoperative findings established the postoperative di-agnosis of ileocecal intussusception (Fig. 3A) due to obstruc-tion caused by a large submucosal benign tumor thathistologically was proved to be a lipoma (Fig. 3B). Postop-eratively, no complications occurred and the patient wasdischarged 6 days after.

DiscussionIntussusception is a relatively frequent cause of intestinalobstruction in infancy and early childhood. Most cases areobserved by age 2 years, and pathology is more frequent inboys.Correspondence to: C. Triantopoulou; email: chatri@mycosmos.gr

AbdominalImaging

© Springer-Verlag New York, LLC. 2004Received: 22 Sept. 2003 / Accepted: 29 Oct. 2003 / Published online: 18 Mar. 2004

Abdom Imaging (2004) 29:426–428DOI: 10.1007/s00261-003-0137-4

In adults intussusception is rare and may present as in-testinal obstruction or an acute abdomen. It may occur as thefirst indication of tumor recurrence or metastasis but morecommonly is a manifestation of widespread disease. How-ever, even in patients with malignant neoplasms, it may beidiopathic or a result of benign tumor [1]. Most neoplasm-related cases are due to large polyps, adenocarcinomas,lymphomas, leiomyosarcomas, melanomas, and, rarely, li-pomas [2, 3].

Colonic lipoma as leading cause is uncommon [4]. Mostare found in the cecum, located submucosally. They aretwice as common in women. Their size has been used as apredictor, with lesions larger than 2 cm causing symptomssuch as abdominal pain, constipation, diarrhea, hemorrhage,or intussusception [5].

Intussusceptions may be enteric, ileocolic, ileocecal, orcolonic. Several possible mechanisms have been proposed toexplain this situation: (a) a tumor may act as a foreign body

causing violent peristalsis, so that the contracted central partof the bowel easily moves into the dilated distal part; (b)intussusception may be due to altered muscle functioncaused by a tumor or bowel paralysis; and (c) a tumor maybe grasped and pulled forward by traction [3, 6].

Common symptoms are abdominal pain, vomiting, andbloody stools presenting for many days or even weeks.Physical examination may show a palpable “sausage-like”mass, and blood tests may show significant leucocytosis [7].

Diagnosis is achieved colonoscopically or radiologically.Hydrostatic barium enema has been the mainstay of nonop-erative treatment, although perforation may occur. Success-ful reduction with barium enema ranges from 50% to 75%,whereas recurrence ranges from 8% to 20%.

Diagnosis of submucosal lipoma can easily be determinedby colonoscopy. On CT lipomas present as round, homoge-neous, well-circumscribed masses with a density differentfrom that of the entrapped mesenteric fat [8].

Recent reports have suggested that abdominal CT is thepreferred radiologic modality for diagnosing intussusceptionfrom colonic lipomas that are well demonstrated due tocharacteristic fatty densitometric values [9]. However, thesefeatures are evident only in large lesions. Smaller onesusually are not detected due to artifacts and partial volumeaveraging. This disadvantage can be eliminated with multi-slice spiral CT scanners.

CT is readily available in most institutions and is notoperator dependent. Low-attenuation lesions withHounsfield units measured at fat density are consistent withlipomas. Differentiating a benign lipoma from a malignantprocess before operation is useful because the diagnosis willaffect the extent of surgical resection.

For patients with features typical of colonic lipoma, CTreliably confirms the diagnosis. However, intussusceptedlipomas may not demonstrate normal fat attenuation andmay have a heterogeneous appearance reflecting the degreeof infarction and fat necrosis present at the time of radiologicevaluation [10]. In our case CT accurately suggested a co-lonic lipoma.

Some investigators have recommended enteroclysis forintussusception diagnosis, but only one case has been re-ported [11].

Magnetic resonance imaging is particularly able to detectfatty lesions because of signal intensity characteristics typi-cal for adipose tissue mainly on T1-weighted and fat-sup-pressed images. However, this imaging modality is seldomused for detecting and studying intestinal neoplastic lesions[9].

Surgical treatment of intussusception is the radical ther-apy, which is followed by minimal recurrence and compli-cations. The time and the type of the surgical interventiondiffer and depend on the site, cause, and degree of obstruc-tion. Intussusceptions caused by submucosal lipomas shouldbe treated conservatively initially and then surgically later ifsymptoms persist and complications are present [6, 12].

Fig. 1. Abdominal CT demonstrates the typical appearanceof ileocecal intussusception, with a large intraluminal lesionwith density values equal to fat.

Fig. 2. Barium enema shows intestinal obstruction at thelevel of the hepatic flexure, where a filling defect is present.

C. Triantopoulou et al.: Intussusception secondary to submucosal cecal lipoma 427

In conclusion, a large submucosal lipoma is a very rarecause of cecal and ileal intussusception that presents asintestinal obstruction in patients without malignancy. Diag-nosis can be determined radiologically or colonoscopically.CT and magnetic resonance imaging remain the methods ofchoice for studying abdominal lipomas, particularly thoserising into the layers of the colonic wall. Initial treatmentshould be conservative. Surgical intervention, which usuallyfollows failure of conservative treatment, permanently re-solves the problem.

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Fig. 3. A Photograph taken during surgery clearly shows the ileocolic intussusception. B Right colectomy specimendemonstrates the macroscopic appearance of colonic lipoma.

428 C. Triantopoulou et al.: Intussusception secondary to submucosal cecal lipoma