Ileo-ileal intussusception in an adult by lipoma

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


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 intussuscipiens 1 .Intussusceptions may be classified as ileocolic, ileocecal, colo-colic and ileo-ileal 2 .Adult intussusception is relatively a rare and is substantially a different clinical entity from paediatric intussusception 3 .Most adult intussusceptions are benign and represents 1% of all bowel obstructions, 5% of all intussusceptions and 0.003%-0.02% of all hospital admissions 4,5 .Adult patients mostly complain of obscure abdominal pain only 6 .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 children 7 .Intestinal lipoma is an uncommon causation of adult intussusception and some lipoma may cause intussusception by acting as the lead point located in the ileum 8,9 .The diagnosis of intussusception is readily suggested because of its pathognomonic appearance on computed tomography 10 .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 adults 11 .The mechanism of intussusception is unclear 12 .Male-to-female ratio is 1:1.3 and mean age of presentation is 54.4 years of adult intussusception 13 .The adult intussusceptions are classified in three steps with aetiology, namely benign, malignant or idiopathic 14 .Intussusception could be either idiopathic type or secondary type 15 .In idiopathic type, intussusception occurs without a lead point lesion.In secondary type intussusception, mostly organic lesions have been implicated [16][17][18][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-Licensee OA Publishing London 2013.Creative Commons Attribution Licence (CC-BY) mately 20% of the adult cases were asymptomatic 20 .Complete bowel obstruction was found in less than 20% of the adult cases.Palpable abdominal mass was present in 7%-42% of the adult cases 3,21 .
Plain abdominal X-ray findings in intussusception show non-specific results suggestive of bowel obstruction.A mass lesion or intraluminal air trapped between the walls of the intussusceptum and intussuscipiens, called as an 'air crescent sign' may be seen on plain radiograph scan 22 .The abdominal ultrasound sonography, in a transverse plane, showed the classic appearance of an intussuscepted bowel, which is called the 'doughnut sign' or a 'target lesion' 23 .This lesion represents several concentric rings of the bowel, with a thick hypoechoic rim, representing an oedematous bowel wall, with an echogenic area in the middle, corresponding to the intussuscepted mesenteric fat.The longitudinal appearance of the intussusception usually appears as multiple parallel lines, the so-called ' sandwich appearance' or 'pseudokidney sign' 24 .Computed tomography is the imaging method of choice for diagnosing adult intussusception.Sensitivity of the computed tomography scan in adult intussusception varies from 71.4%-87.5% 25,26 .A smooth well-circumscribed abdominal mass of fat density (−50 to −100 Hounsfield units) revealed, within the lumen of the bowel that is suggestive of, submucosal intestinal lipoma 27 .
Surgery is the treatment of choice in adult intussusception.In the view of nearly all cases with adult intussusception having an underlying lesion (benign or malignant), surgical intervention is deemed desirable 28 .Manual reduction in small bowel intussusception in an adult patient may be attempted in whom resection of the gut may result in short gut syndrome 29 .

Conclusion
Intussusception in adult is a rare condition.Lipoma, demonstrating as an underlying pathological lead point, is a rare condition.