CASE REPORT

Adult ileoileal intussusception induced by an ileal lipomadiagnosed preoperatively: report of a case and reviewof the literature

Tsutomu Namikawa • Norihiro Hokimoto •

Takehiro Okabayashi • Masamitsu Kumon •

Michiya Kobayashi • Kazuhiro Hanazaki

Received: 24 March 2011 / Accepted: 28 June 2011 / Published online: 14 December 2011

� Springer 2011

Abstract We herein report a case of adult ileoileal intus-

susception induced by an ileal lipoma. A 68-year-old woman

with a history of small intestinal tumors was admitted to our

hospital with severe, colicky lower abdominal pain, similar

to episodes experienced in the past. A barium meal enema at

the initial admission demonstrated a small intestinal tumor in

the ileum 30 cm proximal to the ileocecal valve. Abdominal

ultrasound sonography and computed tomography showed a

sausage-shaped mass presenting as a target sign in the right

lower abdomen, suggestive of intussusception. There was

also a round mass of fat attenuation representing a lipoma,

which was considered the lead point of the intussusception.

The patient underwent emergency surgery and partial

resection of the ileum, including the ileal tumor, following

reduction of the intussusception. The resected specimen

contained a round tumor measuring 1.5 9 1.5 9 1.4 cm,

which was diagnosed histopathologically as an intestinal

lipoma. The patient made a satisfactory recovery and was

discharged on postoperative day 10. The clinical character-

istics of previously reported lipomas with intussusception

are also discussed, including the relationships between the

tumor size and symptoms or location.

Keywords Intussusception � Ileal lipoma � Intestinal

tumor

Introduction

Intussusception is the invagination of a bowel loop together

with its mesenteric fold (intussusceptum) into the lumen of a

contiguous portion of bowel (intussuscipiens). Intestinal

intussusception is an infrequent disease that occurs almost

exclusively in children younger than 4 years of age, and is

seldom encountered in adults. Although intussusception

occurs at all ages, there are major differences in the clinical

presentation, diagnostic approach, and management of

intussusception between the pediatric and adult populations

[1]. Moreover, the exact mechanism that precipitates intus-

susception is still unknown. However, it is generally believed

that any lesion in the bowel wall or irritant within the bowel

lumen could alter the normal peristaltic pattern, and thereby

initiate an invagination leading to intussusception [2].

Adult intussusceptions may be caused not only by

benign lesions such as inflammatory polyps, adenomas,

lipomas, neurofibromas, or adhesions, but also by malig-

nant lesions such as small bowel tumors, including primary

cancers and secondary intestinal metastases of other tumors

[1–4]. Despite the evolution of radiological procedures, the

preoperative diagnosis of adult intussusception remains

challenging, particularly with the lack of specific clinical

symptoms and difficulty in examining the small intestine.

The condition is, therefore, often confirmed only at lapa-

rotomy [4, 5].

Gastrointestinal lipomas are rare benign tumors and an

infrequent cause of intestinal intussusception [2, 4].

Ultrasonography (US) and computed tomography (CT) are

useful, both for confirming the existing diagnosis of

T. Namikawa (&) � N. Hokimoto � T. Okabayashi �K. Hanazaki

Department of Surgery, Kochi Medical School, Kohasu,

Oko-cho, Nankoku, Kochi 783-8505, Japan

e-mail: tsutomun@kochi-u.ac.jp

M. Kumon

Department of Surgery, Noichi Central Hospital, Higashino,

Noichi-cho, Konan, Kochi 781-5213, Japan

M. Kobayashi

Department of Human Health and Medical Science,

Kochi Medical School, Kohasu, Oko-cho,

Nankoku, Kochi 783-8505, Japan

123

Surg Today (2012) 42:686–692

DOI 10.1007/s00595-011-0092-6

intussusception and for providing a pathognomonic diag-

nosis of an intestinal tumor as a leading point of the

intussusception [7, 8]. We herein report a case of adult

ileoileal intussusception induced by an ileal lipoma located

close to the ileocecal junction, which was diagnosed by

abdominal US, CT, and barium meal examination. To the

best of our knowledge, this is the sixth case report of adult

ileoileal intussusception caused by an ileal lipoma diag-

nosed preoperatively.

Case report

A 68-year-old Japanese woman was admitted to our hospital

complaining of right hypochondriac pain. A barium meal

examination showed a filling defect in the ileum, measuring

1.5 cm and with clear margins. Abdominal CT was per-

formed to identify the nature of the lesion, and revealed a

1.5 cm fatty lesion in the small intestine (Fig. 1). A col-

onoscopic examination was performed, but could not reach

the location of the lesion. We made a clinical diagnosis of an

ileal tumor and recommended surgical resection. The patient

did not consent to the operation because her symptoms had

dissipated, and she was subsequently discharged.

However, the patient was readmitted to our hospital

3 months later for colicky epigastric pain with associated

nausea and vomiting. A physical examination revealed a

mild distended abdomen without a palpable mass. The lab-

oratory findings on admission were as follows: normal red

blood cell count (442 9 104/mm3; normal range

370–490 9 104/mm3), increased white blood cell count

(10.2 9 103 mm3; normal range 4.0–8.0 9 103/mm3), and

normal platelet count (15.1 9 104/mm3; normal range

14.5–34.0 9 104/mm3). The total protein, alanine amino-

transferase, aspartate aminotransferase, total bilirubin, and

serum creatinine levels were within the normal range, as

were the serum carcinoembryonic antigen and cancer anti-

gen 19-9 levels.

A barium meal examination on her initial admission

showed a round filling defect measuring 1.5 cm with a

clear margin at the terminal ileum portion proximal to the

ileocecal valve (Fig. 2). During the second admission,

ultrasonography showed a multicentric target sign sug-

gestive of an intussusception in the right lower abdominal

region; the mass comprised hyperechoic mesenteric fat

centrally and a peripheral hypoechoic rim (Fig. 3).

Fig. 1 Abdominal computed tomography showing a fatty oval mass

in the small intestine

Fig. 2 The barium meal examination showed a round filling defect

measuring 1.5 cm with a clear margin at the terminal ileum

Fig. 3 Abdominal ultrasonography showed a target sign composed of

central hyperechoic mesenteric fat (arrowhead) with an entering ileal

loop (short arrow) and hypoechoic thickening of the peripheral ileal

wall (long arrow)

Surg Today (2012) 42:686–692 687

123

Abdominal CT showed a target sign- or sausage-shaped

lesion typical of an intussusception that varied in appearance

relative to the slice axis (Fig. 4). The inner central area

represented the invaginated intussusceptum, surrounded by

its mesenteric fat and associated vasculature, and all sur-

rounded by the thick-walled intussuscipiens (Fig. 4b–d).

More head-side scans showed a low-density homogenous

mass measuring 1.5 cm that was considered to be the leading

point for the invagination (Fig. 4a). These findings led to a

diagnosis of intussusception induced by lipoma.

Under a clinical diagnosis of small intestinal intussusception

caused by an ileal tumor, which was suspected to be a lipoma,

the patient underwent emergency surgery. The ileum, com-

prising approximately 20 cm of intestine, was invaginated at

the terminal end near the ileocecal valve, and an intussuscep-

tion had occurred (Fig. 5). We gently pushed the intussuscep-

tum back from the distal to the proximal ileum to reduce the

lesion. After manual reduction of the intussusception, it was

palpable as an elastic-soft mass of approximately 1.5 cm in

diameter and not invading the serosa. Approximately 5 cm of

ileum, including the tumor, was resected, and an end-to-end

anastomosis was created. Gross examination of the resected

specimen revealed a round tumor covered with mucosa mea-

suring 1.5 9 1.5 9 1.4 cm (Fig. 6). A microscopic examina-

tion revealed fat cells proliferating in the submucosal layer and

confirmed the diagnosis of ileal lipoma (Fig. 7). The postop-

erative course was uneventful, and the patient was discharged

on postoperative day 10.

Discussion

Intussusception is usually a disease of children aged

between 6 months and 4 years, in which the ileum (intus-

susceptum) telescopes into the colon. Adult intussusception

accounts for only 5–10% of all reported cases [5, 9, 10].

Fig. 4 Abdominal computed tomography showed a small intestinal

intussusception. a A smooth-surfaced, round, low-density mass

measuring 1.5 cm considered to be the leading point was observed

at the distal portion of the invaginated bowel (arrow). b, c A target

sign on a transverse view was seen, comprising a ring-shaped mass

with a thick soft tissue density representing the opposing bowel wall

(arrow) and the central low-density mesenteric fat (arrow head). d A

sausage-shaped mass in the longitudinal view that comprised the

edematous bowel wall (arrow) and mesentery within the lumen

(arrowhead)

688 Surg Today (2012) 42:686–692

123

The classic pediatric symptoms of intussusception, such as

abdominal pain, a palpable mass, and blood in the stool are

rarely found in adults, thus leading to the frequent misdi-

agnosis of this disease in the adult population. Further-

more, unlike pediatric cases, adult intussusception is

usually caused by a tumor, which is commonly located at

or near the ileocecal valve and acts as the lead point for the

intussusception [1, 5, 11]. Many cases in adults are,

therefore, secondary to an underlying lesion, and adult

intussusception of the colon is most often secondary to a

malignant tumor, thereby necessitating surgical interven-

tion [12, 13].

A Medline search was performed using the keywords

‘‘adult intussusception’’ and ‘‘lipoma.’’ Fifty cases of adult

intussusception induced by a lipoma, including our present

case, have been reported in the English literature during the

past decade (Table 1). This cohort comprised 28 men and

22 women with a mean age of 52.1 years. The locations of

the lesions were as follows: 2 cases had lesions in the

stomach, 4 were in the jejunum, 21 were in the ileum, 3

were in the cecum, 7 were in the ascending colon, 6 were in

the transverse colon, 4 were in the descending colon, and in

3 cases, the lesion was located in the sigmoid colon. In the

small intestine, such lesions are most commonly located in

the ileum (84%, 21 of 25 patients), while the jejunum is the

least common site for small intestinal lipomas [14]. The

lipoma size ranged from to 1.2 to 12.0 cm, with a mean

size of 4.9 cm.

Among the 50 cases of adult intussusception induced by

a lipoma, CT was used as the diagnostic modality in 45

patients (90%), endoscopic examinations such as esopha-

gogastroduodenoscopy and colonoscopy was used in 22

(44%), US was used in 16 (32%), and an enema contrast

study was used in 11 patients (22%). Abdominal CT is the

most sensitive radiological method for confirming a diag-

nosis of intussusception [13, 14], with the most frequent

finding on plain abdominal radiographs being a mass of

low-density tissue with or without signs of concomitant

intestinal obstruction [15]. On the other hand, intussus-

ception on US invariably appears as a sausage-shaped mass

consisting of concentric rings when the scan plane is par-

allel to its longitudinal axis, which makes a target sign-like

mass when the scan plane is perpendicular to its longitu-

dinal axis [16, 17].

Such radiological examinations of our patient revealed

the presence of mesenteric fat and its associated

Fig. 5 The ileum was invaginated at the terminal ileum and an

intussusception had occurred (arrow)

Fig. 6 The gross appearance of the resected specimen showed a

polypoid mass with a congested mucosal surface

Fig. 7 A histopathologic examination of the tumor revealed fat cells

proliferating in the submucosal layer

Surg Today (2012) 42:686–692 689

123

Table 1 The characteristics of the reported cases of adult intussusception induced by a lipoma

Case Author Year Age Gender Diagnostic

modality

Tumor location Tumor size

(cm)

Reference

1 Alkim C 2001 69 Male US, CS Descending colon 4 J Clin Ultrasound

2 Franc-Law JM 2001 42 Male CS, BE, CT, Descending colon 4.5 Am Surg

3 Park KT 2001 39 Male US, CT Ileum 4 J Korean Med Sci

4 Moues CM 2002 72 Male EGD, US, CT Stomach 10 Dig Surg

5 Ahmed HU 2004 28 Male CT Jejunum 3 Ann R Coll Surg Engl

6 Zissin R 2004 20 Female CT Ileum 18 Emerg Radiol

7 Dawes LC 2004 41 Male CT Ileum ND Australas Radiol

8 Triantopoulou C 2004 44 Female CT, CS, ECS Ileum 5 Abdom Imaging

9 Ghidirim G 2005 51 Female US, ECS, CT Cecum 10 Rom J Gastroenterol

10 Jelenc F 2005 56 Male US, CT Ascending colon 6 J Laparoendosc Adv Surg Tech A

11 Adachi S 2005 50 Male ECS, CS, CT Ascending colon 5 Pathol Int

12 Vinces FY 2005 72 Male CT, EGD Stomach 6 Can J Gastroenterol

13 Meshikhes AW 2005 55 Male CT Ileum ND Surg Today

14 Tsushimi T 2006 63 Female US, CT Ileum 2.5 Surg Today

15 Amer NM 2006 73 Female ECS, MRI Sigmoid colon ND Arch Surg

16 McKay R 2006 63 Male CT Ileum 3 JSLS

17 Chiang TH 2006 85 Male US, CT Jejunum 4 J Gastroenterol Hepatol

18 Huh KC 2006 62 Male CT, CS Sigmoid colon 3.5 Dig Dis Sci

19 Abou-Nukta F 2006 55 Female CT Transverse colon 12 Am Surg

20 Croome KP 2007 31 Female CT Ascending colon 5 Can J Surg

21 Atila K 2007 47 Female US, CT Ileum 5 Ulus Travma Acil Cerrahi Derg

22 Atila K 2007 56 Female US, CS, CT Transverse colon 5 Ulus Travma Acil Cerrahi Derg

23 Fatima H 2007 64 Male CS, CT Transverse colon 6 Clin Gastroenterol Hepatol

24 Manouras A 2007 55 Male CT, ECS Jejunum 4 World J Gastroenterol

25 Duijff JW 2007 42 Male US, CT Ileum 3 Case Rep Gastroenterol

26 Lin MW 2007 47 Female CT Ileum 3 J Laparoendosc Adv Surg Tech A

27 Lin I 2008 47 Female CT, CS, Enema Ascending colon 5 Endoscopy

28 Chen R 2008 36 Male CS, CT, ECS Ileum 9 Cases J

29 Akagi I 2008 36 Male CT, ECS Ileum 4 J Nippon Med Sch

30 Wild D 2008 82 Male CS, CT Sigmoid colon 8 Gastrointest Endosc

31 Martin P 2008 69 Male CT, CS Transverse colon 7 Dig Dis Sci

32 Shpaner A 2008 38 Female CS, CT Ileum 3.3 Clin Gastroenterol Hepatol

33 Gurses B 2008 38 Female US, CT, CS Cecum 6 Emerg Radiol

34 Whitfield JD 2009 45 Male CT Ileum 2.5 N Engl J Med

35 Espinel J 2009 43 Female CS, CT Ascending colon 5 Rev Esp Enferm Dig

36 Espinel J 2009 57 Female CS, CT Transverse colon 5.5 Rev Esp Enferm Dig

37 Chung CS 2009 51 Male US, CT, CS Ileum 3 Gastroenterology

38 Dultz LA 2009 77 Male CT Cecum 3.5 JSLS

39 Lin CW 2009 46 Male CS, CT, ECS Descending colon 6 Endoscopy

40 Shiba H 2009 33 Male CT, CS, BE Ileum 4 Case Rep Gastroenterol

41 Walters JB 2009 32 Female CT Ascending colon 5.8 Gastroenterology

42 Laleman W 2009 49 Male US, CT Descending colon 5 Gastroenterology

43 Paskauskas S 2010 53 Female US, CS, ECS Ascending colon 7 Medicina (Kaunas)

44 Chuang MT 2010 26 Female CT Ileum ND Am J Surg

45 Mason R 2010 51 Female CT Transverse colon 6.2 J Gastroenterol Hepatol

46 Wan XY 2010 68 Male CS Jejunum 3.2 World J Gastroenterol

47 Abbasakoor NO 2010 52 Female CT Ileum 3.2 J Med Case Reports

48 Kuzmich S 2010 62 Female US Ileum 7 J Clin Ultrasound

690 Surg Today (2012) 42:686–692

123

vasculature inside a dilated loop. Furthermore, a homoge-

neous intraluminal mass consistent with fat in the intus-

susception raised the possibility of a lipoma. Accordingly,

CT and US are valuable methods not only for diagnosing

the presence of an intussusception, but also for revealing

the lesion as the leading point or cause of the intussus-

ception. A preoperative diagnosis of intussusception was

made in 21 (42%) patients in our review. Almost all of

these lipomas presented with characteristic fatty densito-

metric values and a smooth margin, and were consequently

well demonstrated by CT or US, which was frequently

pathognomonic.

Previous reports have suggested that 52–80% of adult

cases of small intestinal intussusception are caused by

benign entities such as lipomas, hamartomatous polyps,

inflammatory polyps, hyperplastic polyps, Meckel’s

diverticulum, and surgery-related lesions or adhesions [4,

12]. Indeed, small intestinal tumors are rare, accounting for

only 1–2% of all gastrointestinal tract tumors [6]. Lipomas

of the small intestine are rare benign tumors with no

malignant potential and are most commonly encountered

incidentally, since they are usually asymptomatic [18]. In

the present case, although the initial examination revealed

a fatty, dense mass with clear margins, suggestive of

lipoma, we recommended surgical resection because of the

symptomatic tumor.

In our review of the cases of lipomas with intussus-

ception, abdominal pain that was often colicky and inter-

mittent was the most common clinical presentation (84%,

42 of 50 patients). Other common symptoms were intesti-

nal obstructive syndrome, such as nausea and vomiting,

gastrointestinal bleeding due to ulceration of the overlying

mucosa, and an abdominal palpable mass. However, there

were no significant differences in the tumor size between

patients presenting with and without abdominal pain

(4.9 ± 2.4 vs. 4.9 ± 2.3 cm, P = 0.998). Therefore, it

seems that most lipomas associated with intussusception

give rise to abdominal pain, irrespective of the tumor size.

When the previously reported 50 cases were divided into

two groups according to the tumor location, the tumor size

was significantly greater in the colon group than in the

patients with an upper gastrointestinal tract location,

including stomach and small intestine (6.0 ± 2.0 vs.

4.0 ± 2.1 cm, P = 0.003) (Table 2). The luminal diameter

of the small intestine is smaller than that of the colon, thus,

smaller tumors might result in intussusception more fre-

quently then larger colonic tumors.

Definitive surgical resection remains the recommended

treatment for adult intussusception due to the large pro-

portion of structural causes and the relatively high inci-

dence of malignancy; however, the optimal surgical

management remains controversial [12, 13, 19]. The high

proportion of malignant lesions in adult cases of intussus-

ception argues for resection without reduction procedures,

such as preoperative barium or air. However, in the small

intestine, malignancy is less frequently associated with

intussusception, even though neoplasms remain the leading

causative lesion [11]. Some investigators have stated that

Table 1 continued

Case Author Year Age Gender Diagnostic

modality

Tumor location Tumor size

(cm)

Reference

49 Balamoun H 2011 65 Male CT Ileum 1.2 World J Gastrointest Surg

50 Our case 2011 68 Female US, CT, ECS Ileum 1.5 Surg Today

CT computed tomography, MRI magnetic resonance imaging, CS colonoscopy, ECS enema contrast study, EGD esophagogastroduodenoscopy,

US ultrasonography, ND not described

Table 2 The characteristics of adult intussusception induced by a

lipoma according to the tumor location

Stomach and

small

intestine

Colon P value

Age in years (mean ± SD) 50.1 ± 16.1 54.5 ± 13.5 0.302

Gender 0.283

Male 17 11

Female 10 12

Tumor location

Stomach 2 0

Jejunum 4 0

Ileum 21 0

Cecum 0 3

Ascending colon 0 7

Transverse colon 0 6

Descending colon 0 4

Sigmoid colon 0 3

Tumor size in cm

(mean ± SD)

4.0 ± 2.1 6.0 ± 2.0 0.003

Diagnosis 0.704

Preoperative 12 9

Postoperative 15 14

Surg Today (2012) 42:686–692 691

123

small bowel intussusception should still be reduced only in

patients in whom a definitive benign diagnosis has been

made preoperatively, or in patients in whom resection may

result in short gut syndrome [13, 19]. However, without

reduction, the surgical resection of a long segment of

intussusception often necessitates the excision of more of

the intestine than necessary to remove the tumor, because it

might also compromise the mesenteric vessels. Therefore,

reduction could be attempted if the involved bowel seg-

ment is viable and when a diagnosis of a benign lesion has

been reached preoperatively. Such an approach results in

less invasive surgery for the intussusception and may thus

allow surgeons to avoid an overly extensive resection of

the intestine.

The present case highlights the possibility of intussus-

ception with an unusually benign cause, such as lipoma,

when adult patients present with nonspecific abdominal

symptoms and small bowel obstruction. Additional reports

of intussusception in the adult population are needed to

optimize the standard management for this uncommon

disease.

Conflict of interest Tsutomu Namikawa and other co-authors

declare no conflicts of interest.

References

1. Demirkan A, Yagmurlu A, Kepenekci I, Sulaimanov M, Gecim

E, Dindar H. Intussusception in adult and pediatric patients: two

different entities. Surg Today. 2009;39:861–5.

2. Weilbaecher D, Bolin JA, Hearn D, Ogden W. Intussusception in

adults. Review of 160 cases. Am J Surg. 1971;121:531–5.

3. Shi B, Gaebelein G, Hildebrandt B, Weichert W, Glanemann M.

Adult jejunojejunal intussusception caused by metastasized

pleomorphic carcinoma of the lung: report of a case. Surg Today.

2009;39:984–9.

4. Chiang JM, Lin YS. Tumor spectrum of adult intussusception.

J Surg Oncol. 2008;98:444–7.

5. Nagorney DM, Sarr MG, Mcllrath DC. Surgical management of

intussusception in the adult. Ann Surg. 1981;193:230–6.

6. Good CA. Tumor of the small intestine. AJR Am J Roentgenol.

1963;89:695–705.

7. Whitfield JD, Mostafa G. Images in clinical medicine: ileocecal

intussusception. N Engl J Med. 2009;361:55.

8. Meshikhes AW, Al-Momen SA, Al Talaq FT, Al-Jaroof AH.

Adult intussusception caused by a lipoma in the small bowel:

report of a case. Surg Today. 2005;35:161–5.

9. Reijnen H, Joosten H, de Boer H. Diagnosis and treatment of

adult intussusception. Am J Surg. 1989;158:25–8.

10. Lorigan JG, Dubrow RA. The computed tomographic appear-

ances and clinical significance of intussusception in adults with

malignant neoplasm. Br J Radiol. 1990;63:257–62.

11. Felix EL, Cohen MH, Bernstein AD, Schwartz JH. Adult intus-

susception; case report of recurrent intussusception and review of

the literature. Am J Surg. 1976;131:758–61.

12. Azar T, Berger DL. Adult intussusception. Ann Surg. 1997;226:

134–8.

13. Eisen LK, Cunningham JD, Aufses AH Jr. Intussusception in

adults: institutional review. J Am Coll Surg. 1999;188:390–5.

14. Manouras A, Lagoudianakis EE, Dardamanis D, Tsekouras DK,

Markogiannakis H, Genetzakis M, et al. Lipoma induced je-

junojejunal intussusception. World J Gastroenterol. 2007;13:

3641–4.

15. Urbano J, Serantes A, Hernandez L, Turegano F. Lipoma-induced

jejunojejunal intussusception: US and CT diagnosis. Abdom

Imaging. 1996;21:522–4.

16. Gayer G, Zissin R, Apter S, Papa M, Hertz M. Pictorial review:

adult intussusception: a CT diagnosis. Br J Radiol. 2002;75:185–

90.

17. Kuzmich S, Connelly JP, Howlett DC, Kuzmich T, Basit R,

Doctor C. Ileocolocolic intussusception secondary to a submu-

cosal lipoma: an unusual cause of intermittent abdominal pain in

a 62-year-old woman. J Clin Ultrasound. 2010;38:48–51.

18. Zografos G, Tsekouras DK, Lagoudianakis EE, Karantzikos G.

Small intestinal lipoma as a cause of massive gastrointestinal

bleeding identified by intraoperative enteroscopy. A case report

and review of the literature. Dig Dis Sci. 2005;50:2251–4.

19. Nagorney DM, Sarr MG, McIlrath DC. Surgical management of

intussusception in the adult. Ann Surg. 1981;193:230–6.

692 Surg Today (2012) 42:686–692

123