Open Access

Resolution of intussusception after spontaneous expulsion of an ileal lipoma per rectum: a case report and literature review

  • Bin Kang1,
  • Qingkai Zhang1,
  • Dong Shang1Email author,
  • Qingqiang Ni1,
  • Faheem Muhammad1,
  • Li Hou2 and
  • Wenjun Cui3
World Journal of Surgical Oncology201412:143

https://doi.org/10.1186/1477-7819-12-143

Received: 15 March 2014

Accepted: 20 April 2014

Published: 7 May 2014

Abstract

We herein report a case of spontaneous rectal expulsion of an ileal lipoma in a 65-year-old female patient who presented with recurrent attacks of subacute intestinal obstruction. During each episode, the patient developed severe abdominal pain and expelled a fleshy mass from her rectum. The fleshy mass was histopathologically diagnosed as a lipoma comprising fat cells, fibers, and blood vessels. Upon expulsion, the pain disappeared and the intussusception was immediately resolved. Colonoscopic examination revealed a 2.5-cm diameter ulcerated lesion near the ileocecal valve, which was confirmed to be inflammation by pathological examination. A subsequent barium series revealed a normal colonic tract, and the patient remained completely symptom-free for 4 months after the incident. According to the relevant literature and our clinical experience, the treatment method for a lipoma depends on the patient’s clinical manifestations and the size of the tumor. However, the various diagnostic and therapeutic modalities currently available continue to be debated; whether an asymptomatic lipoma requires treatment is controversial. When histopathological examination results allow for the exclusion of malignant lesions such as sarcoma, a lipoma can be resected surgically.

Keywords

Expulse Intussusception Lipoma Self-healing Small intestine

Background

Small intestinal tumors are extremely rare, accounting for only 1% to 2% of gastrointestinal tumors worldwide [1], and only around 30% of small intestinal tumors are benign. Lipoma, which is less prevalent than leiomyoma and adenoma, is the third most common primary benign tumor in the gut [2]. Small bowel tumors are rare entities that often present with nonspecific symptoms. When these tumors are >2 cm in diameter, abdominal pain, hematochezia, and/or incomplete intestinal obstruction may appear. The lack of specific clinical manifestations makes it difficult to reach a definite preoperative diagnosis; sometimes the lipoma is even ignored after the development of an intussusception. Moreover, it is difficult to identify symptomatic patients with malignant tumors, which can consequently be misdiagnosed. Most intestinal lipomas are located in the distal ileum and colorectal region (mainly the right colon) and are rarely located in the stomach or proximal small intestine. Intestinal lipomas seldom deteriorate, and they do not relapse after cure.

Intussusception was reported for the first time in 1674 by Barbette of Amsterdam [3]. The development of intussusception in adults is extremely rare and has a variety of etiologies. Neoplasia is the most common cause and is present in approximately 65% of adult intussusception cases [4]. Adult patients with intussusception may or may not be symptomatic, and symptoms can be acute, intermittent, or chronic. Therefore, intussusception is difficult to diagnose. The manifestations of symptomatic lipoma include abdominal pain, hemorrhage, or incomplete intestinal obstruction. Because of their intramural location, lipomas can also serve as the leading point for intussusceptions. A correct and timely diagnosis is important to avoid complications such as bowel infarction and perforation secondary to obstruction.

Case presentation

A 65-year-old woman was admitted to the emergency department with a 3-year history of intermittent abdominal pain that was exacerbated and accompanied by nausea for the past 5 days. The pain was moderate, paroxysmal, and colicky in nature; it was present mainly in the right lower quadrant and radiated to the back. She had no fever and reported intermittent defecation without nausea or vomiting. The patient had previously been seen at another hospital, where abdominal ultrasound and computed tomography (CT) examination revealed either a smooth, well-circumscribed mass within the lumen of the bowel or an intussusception. Her symptoms improved after conservative treatment. Physical examination revealed tenderness in the right lower quadrant and a smooth, well-circumscribed mass of approximately 7.0 × 5.0 cm was palpated in the epigastrium. Abdominal CT revealed a small bowel intussusception in the right epigastric region (Figure 1A and B).
Figure 1

Transverse and coronary contrast-enhanced computed tomography (CECT) of the abdomen. (A) Transverse CECT showed the bowel intussusception (white arrow) entered the intestinal lumen on the right middle abdomen. Enhanced blood vessel (yellow arrow) also entered the intestinal lumen along with the bowel. (B) Coronary CECT showed that the tumor was located at the splenic flexure of the colon (blue arrow) and was accompanied by local intestinal expansion.

The patient had no history of surgery, trauma, or other diseases. Laboratory test results showed a white blood cell count of 7.80 × 109/L, a neutrophil level of 71.3%, and a hemoglobin level of 104 g/L. Other examination results were normal. The preliminary diagnosis was considered to be an intestinal tumor with intussusception.

After admission, the patient was treated with oral therapy for bowel lubrication and experienced gradual relief of her abdominal pain. A vegetative mass was then extruded from the rectum when the patient defecated. However, it could not be completely discharged. Digital rectal examination revealed a well-circumscribed neoplasm with poor mobility in the center of the rectal lumen. A small amount of blood was present on the glove after digital examination. Abdominal CT showed a mass shadow in the ileocecal valve region with a maximum size of approximately 2.90 × 3.22 cm (Figure 2A) and an expanded rectum with fat density and space within a shadow (Figure 2B). We actively enlarged the anus and administered a strong oral laxative. The patient then successfully defecated the mass. The mass was approximately 7.0 × 4.5 × 3.6 cm in size and of medium hardness; it had a smooth gray surface and a fine texture (Figure 3A). Microscopic examination showed fat cells, blood vessels, and fiber cells arranged in a leaf pattern, with no heterogeneous nucleus or seedless division in the submucosal layer. The pathologic diagnosis was a bleeding submucosal lipoma with intestinal mucosal necrosis (Figure 3B).
Figure 2

Computed tomography (CT) of the abdomen. (A) CT showed a mass shadow in the ileocecal valve with a maximum size of 2.90 × 3.22 cm (yellow arrow). (B) CT showed the rectum expanded with fat density and space inside a shadow (white arrow).

Figure 3

Tumor and histopathological features. (A) A mass section showed a gray surface and fine texture by formalin infiltration. (B) Microscopic examination showed fat cells, blood vessels, and fiber cells arranged in a leaf pattern, with no heterogeneous nucleus or seedless division in the submucosal layer (hematoxylin and eosin staining, ×40).

After expulsion of the mass, the abdominal pain was completely relieved. Follow-up abdominal CT showed that the mass in the splenic flexure of the colon had disappeared and that the intussusception had been resolved. Colonoscopy showed an ulcerative lesion approximately 2.5 cm in diameter near the ileocecal valve that was surrounded by mucosal congestion (Figure 4A). Microscopic examination revealed regularly arranged glands; the epithelia were not atypical, but interstitial edema, eosinophils, and lymphocyte infiltration were present (Figure 4B). The pathologic diagnosis was inflammation of the ileocecal valve. Four months later, colonoscopy indicated that the inflammation of the ileocecal valve had healed and that the mucosa was intact. Subsequent capsule endoscopy and enteroscopy examination demonstrated no pathological changes.
Figure 4

Colonoscopy and histopathological features. (A) Colonoscopy showed an approximately 2.5-cm diameter ulcerative lesion (blue arrow) near the ileocecal valve, surrounded by mucosal congestion. (B) Microscopic examination showed regularly arranged glands and epithelia with no atypia, but interstitial edema, eosinophils, and lymphocyte infiltration were present (hematoxylin and eosin staining, ×100).

Discussion

When the lipoma moved to the splenic flexure, as in this case, abdominal CT still showed signs of intussusception, indicating that the mass was connected to a pedicle. The long duration of the intussusception, the gravity of the lipoma, and the presence of intestinal peristalsis gave rise to ischemia, necrosis, and breakage of the pedicle. Thus, the lipoma fell from the descending colon to the rectum, and the intussusception was resolved. After anal dilatation and catharsis treatment, the mass was spontaneously expelled. Abdominal CT and colonoscopy showed the mass shadow with an ulcerative lesion near the ileocecal valve as well as congestion of the surrounding mucosa. We consider that the mass shadow was caused by intestinal edema and thickening. The ulcerative lesion may have been caused by the impression of the mass when it fell to the ileocecal valve.

An intestinal lipoma is a benign tumor that can appear in any part of the gut. The terminal ileum is the most common location in the small intestine. There are three pathological types of intestinal lipomas. The submucosal type is the most common, accounting for more than 90% of intestinal lipomas, and grows within the submucosal layer, protruding into the lumen. The intermuscular type is located within the muscular layer. The subserosal type, which is asymptomatic, grows within the subserosal layer and protrudes out of the gut. Larger lipomas can be palpated as a smooth, movable abdominal lump. The tumor in our case was a submucosal lipoma. The patient spontaneously expelled the lipoma from her rectum before the development of intestinal ischemia and necrosis, and the intussusception was resolved spontaneously.

Imaging examination and colonoscopy contribute to the preoperative diagnosis of intestinal lipomas. Intestinal lipomas can be diagnosed by conventional endoscopy, capsule endoscopy, and barium examination. The presence of a round filling defect with or without a pedicle in the lumen on barium enema examination or small intestinal barium enema intubation examination indicates a lipoma. Ultrasound is usually the first diagnostic modality chosen, especially when the lipoma is accompanied by intestinal intussusception. The characteristic ultrasound finding associated with an intussusception is the “target sign”, in which the outermost layer represents the sheath, and the multilayer ring structure represents the invaginated intestinal segment. In some cases, ultrasonography can show a suborbicular nested mass with a clear boundary, low blood supply, and strong ultrasonic echo. These findings may indicate a lipoma. However, ultrasonography is generally limited to the demonstration of intestinal dilation and obstruction. CT is the most valuable diagnostic method for intestinal intussusception, and it can clearly reveal the typical characteristics of uniform tumor density, a clear border, no reinforcement, and fat (negative) density, allowing for a definite diagnosis [5]. Colonoscopy is also valuable in the diagnosis of intestinal lipoma. Microscopically, a lipoma is characterized as follows: i) it presents as an orange, smooth, submucosal mass protruding into the intestinal lumen with or without a pedicle; ii) the mass can immediately recover from local compression using biopsy forceps (the so-called “cushion sign”); and iii) after repeated biopsy of a certain part of the tumor, the submucosal adipose tissue is visible (termed “naked fat”) [6]. However, endoscopy is of little significance for the diagnosis of intestinal lipoma.

We searched the PubMed database to gain a deeper understanding of lipomas in the small intestine. The following search terms were used: ((lipoma [MeSH Terms]) OR lipoma) AND ((intestine, small [MeSH Terms]) OR small intestine OR small bowel) AND (English [Language]) AND (intussusception [MeSH Terms]). Only 51 eligible articles were retrieved. We excluded articles that described secondary cases or the imaging characteristics of lipomas in the small intestine and only 27 articles remained [733] (Table 1).
Table 1

Characteristics of reported cases of adult intussusception induced by a lipoma

Case

Sex

Age (years)

Presentation

Diagnostic modality

Diagnosis

Tumor location

Size (cm)

Treatment

Follow-up

Authors

1

Female

29

Abdominal pain

US, CT

Angiolipoma

Ileum

4.3 × 2.5

Exploratory laparotomy

Uneventful

Esnakula K et al. [7]

2

Male

37

Abdominal pain, constipation, and rectal prolapse

Colonoscopy, CT

Colonic lipoma

Colon

5.5

Resection

Well

Pezzolla A et al. [8]

3

Male

75

Rectal bleeding and anemia

Colonoscopy

Lipoma

Ileocecal valve

2.7 × 2.6 × 2.2

Endoscopic resection

Well

Pezzolla A et al. [8]

4

Female

51

Abdominal pain, constipation, and rectal prolapse

Colonoscopy

Lipoma

Sigmoid colon

10.0

Mini-laparotomy

Well

Pezzolla A et al. [8]

5

Male

73

Abdominal pain, nausea, vomiting, and hematochezia

Video capsule endoscopy, CT

Lipoma

Mid-jejunum

2.1

Resection

Well

Lucas LC et al. [9]

6

Female

43

Nausea and upper abdominal pain

MDCT, US

Submucosal lipoma

Small intestine

2.4 × 2.0 × 2.0

Laparotomy

Uneventful

Ako E et al. [10]

7

Female

26

Abdominal pain and vomiting

Plain abdominal film, CT

Ectopic pancreas with abundant fatty infiltration

Small bowel

No exact data

Laparotomy

Unknown

Chuang MT et al. [11]

8

Male

68

Abdominal bloating

DBE

Multiple submucosal lipomas

Jejunum

From 5.5 × 6.0 to 8.5 × 7.5

Resection

Well

Wan XY et al. [12]

9

Male

78

Constipation, nausea, and vomiting

Plain abdominal film, CT

Submucosal lipoma

Ileum

4.0

Resection

Well

Di Saverio S et al. [13]

10

Male

45

Abdominal pain, nausea, and vomiting

CT

Lipoma

Terminal ileum

2.5

Laparoscopy and resection

Well

Whitfield JD et al. [14]

11

Female

62

Abdominal pain, alternating bowel habits, and weight loss

US

Submucosal lipoma

Ileocecal valve

7.0 × 3.0 × 2.5

Laparotomy and right hemicolectomy

Well

Kuzmich S et al. [15]

12

Male

36

Epigastric pain, nausea, and vomiting

X-ray, US, CT

Ileal lipoma

Ileum

2.7 × 2.7 × 4.0

Resection

Well

Akagi I et al. [16]

13

Female

47

Nausea, vomiting, and abdominal pain

CT

Submucosal lipoma

Small intestine

3.0 × 3.0

Laparoscopy and resection

Well

Lin MW et al. [17]

14

Male

54

Acute abdominal pain, nausea, and vomiting

Colonoscopy, X-ray, CT

Lipoma

Ileum

No exact data

Laparoscopy and resection

Well

Oyen TL et al. [18]

15

Female

65

Abdominal cramps and hematochezia

US, CT

Submucosal lipoma

Ileocecal

No exact data

Laparotomy and right hemicolectomy

Well

Rathore MA [19]

16

Male

63

Mid abdominal pain, flatus, and nausea

CT

Lipoma

Ileocecal valve

No exact data

Laparoscopy

Uneventful

McKay R [20]

17

Male

28

Cramps and abdominal pain, vomiting, and diarrhea

X-ray, CT

Meckel’s diverticulum lipoma

Jejunum

3.0

Laparotomy

Uneventful

Ahmed HU et al. [21]

18

Female

20

Cramps and abdominal pain

CT, CECT

Sub mucosal tumor

Small intestine

1.8

Laparotomy

Uneventful

Zissin R [22]

19

Male

40

Cramps and abdominal pain, nausea, and vomiting

CT, MRI, small intestinal barium X-ray

Sub mucosal lipoma

Small bowel

10.0 × 3.0 × 2.0

Laparotomy and reduction

Uneventful

Marino F et al. [23]

20

Male

55

Colicky epigastric pain, nausea, and abdominal distention

X-ray, US, CT

Lipoma

Terminal ileum

No exact data

Laparotomy

Well

Meshikhes AW et al. [24]

21

Male

72

Lack of appetite, early satiety, and nausea

US, CT

Lipoma

Jejunum

10.0 × 5.0

Laparotomy

Uneventful

Mouës CM et al. [25]

22

Male

59

Lower abdominal pain

X-ray, US, colonoscopy, EUS

Lipoma

Ileum

2.7 × 1.9 × 1.9

Laparotomy

Unknown

Watanabe F et al. [26]

23

Female

80

Colicky upper abdominal pain

CT

Lipoma

Jejunum

No exact data

Resection

Well

Ross GJ et al. [27]

24

Female

68

Periumbilical colicky pain, nausea, and vomiting

X-ray, US, CT

Submucosal lipoma

Jejunum

3.5

Resection

Uneventful

Urbano J et al. [28]

25

Male

43

Crampy right upper quadrant pain

X-ray, CT

Multiple submucosal lipomas

Small bowel

1.0–4.0

Laparotomy

Repeat laparotomy due to necrotic bowel

Gates LK Jr et al. [29]

26

Male

12

Cough, vomiting, and intermittent epigastric pain

US, ERCP, barium meal, CT

Submucosal lipoma

Duodenal

10.0 × 6.0 × 4.0

Laparotomy

Unknown

McGrath FP et al. [30]

27

Male

32

Colicky abdominal pain

X-ray, barium meal

Lipoma

Small intestine

8.0 × 5.0

Conservative

Well

Misra SP et al. [31]

28

Female

42

Colicky periumbilical and right upper quadrant pain

Barium enema, CT

Lipoma

Ileocecal valve

3.0

Laparotomy

Unknown

Donovan AT et al. [32]

29

Male

60

Melena

Barium enema

Lipoma

Terminal ileum

2.0 × 3.0 × 4.0

Resection

Unknown

Schnur MJ et al. [33]

30

Female

40

Rectal bleeding

Barium enema

Submucosal lipoma

Terminal ileum

6.0

Resection

Unknown

Schnur MJ et al. [33]

31

Male

65

Small bowel obstruction

Barium enema

Malignant carcinoid tumor

Terminal ileum

0.5 × 1.5 × 3.0

Resection

Unknown

Schnur MJ et al. [33]

32

Male

75

Cramp and abdominal pain

Barium enema

Lipoma

Terminal ileum

5.0

None

Unknown

Schnur MJ et al. [33]

33

Female

74

Rectal bleeding

Barium enema

Lipoma

Terminal ileum

1.0

None

Well

Schnur MJ et al. [33]

Abbreviations: CT Computed tomography, CECT Contrast-enhanced computed tomography, MDCT Multidetector row computed tomography, MRI Magnetic resonance imaging, US Ultrasonography, EUS Endoscopic ultrasonography, ERCP Endoscopic retrograde cholangiopancreatography, DBE Double-balloon endoscopy.

According to the literature, most lipomas are asymptomatic. They may present as intestinal obstruction or hemorrhage [34]. The lack of specific clinical manifestations makes small intestinal lipomas difficult to diagnose. Their usual location in the small intestine is the ileum. The peak age of incidence is the sixth to seventh decade of life. Despite the development of imaging techniques, only 32% to 50% of cases are diagnosed preoperatively [35]. Intestinal lipomas >2 cm in diameter can cause intussusception. The typical triad of abdominal pain, a sausage-shaped mass, and red jelly stools is seen in children, but rarely in adults. Adult intussusception is a very rare condition, accounting for only around 5% of all intussusception cases and 1% of adult intestinal obstructions [36]. If a lipoma is <2 cm in diameter, it can be resected via endoscopy. However, this method is risky for lipomas with no pedicle. Because fat is a poor conductor, it does not readily solidify after electric coagulation. Bleeding and deep tissue damage may occur. The electric current accumulation during coagulation greatly contributes to the risk of intestinal perforation. Therefore, local intestinal resection is the optimal treatment method. When a lipoma causes intussusception, the intestinal tract should be intraoperatively reset and the local intestine then resected. Otherwise, intestinal resection with anastomosis is feasible. If the condition cannot be diagnosed preoperatively, intraoperative pathological examination helps to determine the best surgical treatment method. In addition, some colonic lipomas are accompanied by colorectal cancer. The intestinal tract should be thoroughly explored during surgery to prevent misdiagnosis.

Definitive surgical resection remains the recommended treatment for adult intussusceptions due to the large proportion of structural causes and the relatively high incidence of malignancy. However, the most optimal surgical management technique remains controversial. Some investigators have stated that small bowel intussusceptions should be reduced only in patients in whom a definitive benign diagnosis has been made preoperatively and should be avoided in patients in whom resection may result in short-bowel syndrome [35]. All surgeons agree that intestinal resection is optimal if there are signs of irreversible bowel ischemia, inflammation, or suspected malignancy [37]. Otherwise, reduction is appropriate, especially when the small bowel is affected, because a considerable length of the bowel can be preserved, thereby preventing the development of short-bowel syndrome.

Conclusions

In summary, the treatment of intestinal lipoma depends on the clinical manifestations and the size of the tumor. Whether small asymptomatic lipomas need further treatment remains controversial. For symptomatic lipomas, operative resection can be performed to histopathologically exclude liposarcoma and malignant lesions. Laparoscopic operative resection is superior to the traditional open operation. In the presence of complications such as acute intestinal obstruction, intussusception, or massive hemorrhage, operative treatment is recommended. In patients with intestinal ischemia, necrosis, or suspected malignancy, intestinal resection and anastomosis is feasible. Otherwise, reduction is appropriate and prevents the development of short-bowel syndrome.

In this paper, we have described a case involving a lipoma in the terminal ileum. Ultrasonographic and whole-abdomen CT examination showed that the lipoma had caused an ileocolic intussusception and incomplete intestinal obstruction. After the onset of the ileocecal intussusception, the site slowly expanded toward the ascending colon, transverse colon, and splenic flexure of the colon. The lipoma finally fell to the rectum, and intussusception resolved spontaneously.

Consent

Written informed consent was obtained from the patient for publication of this case and for the accompanying images.

Authors’ information

The English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, please see: http://www.textcheck.com/certificate/p5Hkrp.

Abbreviations

CECT: 

Contrast-enhanced computed tomography

CT: 

Computed tomography

DBE: 

Double-balloon endoscopy

ERCP: 

Endoscopic retrograde cholangiopancreatography

EUS: 

Endoscopic ultrasonography

MDCT: 

Multidetector row computed tomography

MRI: 

Magnetic resonance imaging

US: 

Ultrasonography.

Declarations

Acknowledgments

We thank Prof. Dong Shang for assisting in the preparation of this manuscript.

Authors’ Affiliations

(1)
Department of Acute Abdominal Surgery, First Affiliated Hospital, Dalian Medical University
(2)
Department of Pathology, Dalian Medical University
(3)
Department of Radiology, First Affiliated Hospital, Dalian Medical University

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