CASE REPORT OPEN ACCESS

International Journal of Surgery Case Reports 10 (2015) 134137

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International Journal of Surgery Case Reports

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Adult sigmoidorectal intussusception related to colonic lipoma: A rare

case report with an atypical presentation
Mohamed Mohamed , Karim Elghawy, Donald Scholten, Kenneth Wilson,
Michael McCann
Trauma Services Department, Hurley Medical Center, One Hurley Plaza, Flint, MI 48503, USA

a r t i c l e

i n f o

Article history:
Received 25 February 2015
Received in revised form 16 March 2015
Accepted 18 March 2015
Available online 20 March 2015
Keywords:
Intussusception
Adult
Sigmoid
Rectal
Lipoma
Colon

a b s t r a c t
INTRODUCTION: Adult intussusception is rare. Lipoma is the second most common benign tumor of the
colon and most common to cause colonic intussusception in adults, but rare.
PRESENTATION OF CASE: A 35-years-old male presented with a history of intermittent abdominal pain
and bright red rectal bleeding, with symptoms waxing and waning for one month. On physical examination, the abdomen was distended with tenderness over the periumbilical, suprapubic, and left lower
quadrant regions with guarding. CT demonstrated colo-colonic intussusception of the sigmoid colon with
a 2.3 cm 2.6 cm intra-mural lipoma of the rectosigmoid region. The patient underwent an exploratory
laparotomy with partial reduction of the intussusception, sigmoid colon resection and end colostomy.
Histopathology conrmed a 2.5 cm sub-mucosal lipoma without evidence of malignancy.
DISCUSSION: Sixtysixty ve percent of cases with intussusception of the large bowel in adults are related
to a malignant etiology and most cases of sigmoidorectal intussusception reported in the literature are
secondary to underlying malignancy. Colo-colic intussusception is the most common type of intussusception in adults. The incidence of lipomas of the large intestine is reported to range from 0.035% to
4.4%. Ninety percent of colonic lipomas are submuscosal and are mostly located in the right hemicolon.
Only 25% of patients with colonic lipoma develop symptoms. Colonic lipomas of the rectosigmoid region
represent a very rare occurrence and subsequent etiology for sigmoidorectal intussusceptions in adults.
CONCLUSION: Colonic lipoma should be considered in the differential diagnosis of adults with intussusception, with reduction and resection leading to excellent results.
2015 Z. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article
under the CC BY-NC-SA license (http://creativecommons.org/licenses/by-nc-sa/4.0/).

1. Introduction
Intussusception in adults is rare and accounts for less than 5% of
all intussusception cases [1]. Colonic lipoma is rare, and can serve
as the lead point for intussusception [2,3].Adult intussusception
cases present with nonspecic signs and symptoms and CT scan is
the most sensitive diagnostic modality. We report a sigmoidorectal intussusception in an adult in whom an intramural lipoma was
identied as the lead point.
2. Presentation of case
A 35-year-old male, with no prior medical or surgical history,
presented to the emergency department with a history of progressive abdominal pain and bright red rectal bleeding between and

Corresponding author at: Trauma Services Department - 7W, Hurley Medical

Center One Hurley Plaza Flint, MI 48503, USA. Tel.: +1 810 262 6023; fax: +1 810
262 6341.
E-mail address: mmohame4@hurleymc.com (M. Mohamed).

after bowel movements, with symptoms waxing and waning for

one month. On presentation, he experienced severe, constant, sharp
non-radiating lower abdominal pain described as 10/10 followed
by a single episode of greenish emesis.
On physical examination, the patient was in painful distress.
Vital signs were normal. The abdomen was distended with tenderness over the periumbilical, suprapubic, and left lower quadrant
regions with guarding. There was no nausea, constipation, diarrhea
or rectal pain. Bowel sounds were normal. There were no additional
signs to suggest peritonitis or acute intestinal obstruction. Threeview plain abdominal x-rays were performed and did not show
signs of obstruction or perforation. CT of the abdomen and pelvis
demonstrated colo-colonic intussusception of the sigmoid colon
with a 2.3 cm 2.6 cm intra-mural lipoma of the recto-sigmoid
region likely to be the lead point and no signs of large bowel
obstruction (Figs. 14). In the absence of signs suggestive of acute
intestinal obstruction and apparent benign nature of the mass
on CT, the patient was admitted for initial lower gastrointestinal
endoscopy to conrm the lipoma and exclude malignancy. Reexamination on post-admission day one revealed a soft, mildly
distended abdomen without guarding and with normal bowel

http://dx.doi.org/10.1016/j.ijscr.2015.03.035
2210-2612/ 2015 Z. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-SA
license (http://creativecommons.org/licenses/by-nc-sa/4.0/).

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M. Mohamed et al. / International Journal of Surgery Case Reports 10 (2015) 134137

135

Fig. 1. Axial view showing the proximal part of the colo-colonic intussusception of
the sigmoid colon.

Fig. 4. Sagittal view showing mass (lipoma) lling the distal sigmoid.

Fig. 2. Axial view showing a mass (lipoma) lling the distal sigmoid colon that was
the lead point.

Fig. 5. Colonoscopy showing obstruction/intussusception.

Fig. 3. Coronal view.

sounds. Vital signs remained within normal. Lower gastrointestinal endoscopy was performed and proctoscopy revealed congested,
friable colonic mucosa that completely lled the rectal lumen without evidence of malignancy (Fig. 5). Reduction was not attempted
as it did not appear feasible. Exploratory laparotomy was carried
and reduction of the intussusception was attempted. Only partial
reduction was possible and segmental sigmoidectomy (21 cm) was
performed leaving approximately 10 cm of intussusceptum within
the intussuscepiens. The condition of the bowel was sub-optimal
for primary anastomosis. Both bowel segments after resection were
inamed and edematous, thus end colostomy was performed. The

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M. Mohamed et al. / International Journal of Surgery Case Reports 10 (2015) 134137

histopathology report conrmed a 2.5 cm sub-mucosal lipoma with

no evidence of dysplasia or malignancy. The postoperative period
was uneventful and the patient was discharged on the fth postoperative day. The patient underwent an elective reversal of his
colostomy with primary anastomosis after 6 months of follow-up
and is doing well.

3. Discussion
Adult intussusception is a rare clinical condition which constitutes less than 5% of all cases of intussusception and 13% of all
cases of intestinal obstruction [1]. Intussusception is a process in
which a proximal segment of bowel telescopes or invaginates into
an adjacent distal segment. The pathophysiology usually involves
a lesion in the bowel wall or an irritant in its lumen serving as a
lead point that may change the normal peristaltic pattern and initiate the invagination leading to intussusception. Intussusception
that occurs in absence of a lead point is classied as primary or
idiopathic and is more likely to occur in the small intestines, or as
secondary when a lead point is identied [1,4].
Secondary intussusception can be due to benign, malignant, or
iatrogenic causes [5]. In adults, intussusception has an identiable
etiology in 90% of cases [6]. In the small intestine, benign lesions
represent the majority of lead points, and only 2530% are malignant lesions [1,7]. Conversely, 6065% of cases of intussusception
occurring in the large bowel have a malignant etiology [1].
Lipomas may occur throughout the intestinal tract with highest
incidence in the colon [6]. The reported incidence of lipomas of
the large intestine ranges from 0.035% to 4.4% [6,8]. Ninety percent
of colonic lipomas are submucosal and mostly located in the right
hemicolon [6,8]. Lipomas larger than 4 cm are considered giant, and
those larger than 2 cm in diameter can cause bowel obstruction
without intussusception [6,9,10]. Over a period of 45 years, only 46
cases of colonic intussusception secondary to colonic lipomas have
been reported in the English language literature [6].
Intussusception may be classied into 4 main types depending
on its location: (1) entero-enteric involving the small intestine,
(2) colo-colic involving the large intestine, (3) ileo-colic involving the terminal ileum and ascending colon, and [4] ileo-cecal
involving the ileo-cecal valve as the lead point. In clinical practice, it is difcult to distinguish between ileo-colic and ileo-cecal
[1]. In adults, colo-colic intussusception is the most common type
[11]. The colo-colic entity may be further sub-classied into: (1)
colo-rectal colon invaginates through rectal ampulla and (2)
recto-rectal with rectum invaginating into the rectum but with
no anal protrusion [1]. Other rare reported locations not included
in this classication are gastroduodenal intussusception, and retrograde jejunogastric intussusception following gastro-jejunostomy.
Early diagnosis of adult intussusception is a challenging task
because most cases present with non-specic signs and symptoms and have a chronic or sub-acute course. Abdominal pain is
the most common presenting symptom before intussusception.
Colonic lipomas are usually asymptomatic but may rarely cause
bleeding, obstruction and intussusception. The four cardinal symptoms of bowel obstruction are pain, vomiting, obstipation/absolute
constipation, and distention. Obstipation, change in bowel habits,
complete constipation, and abdominal distention are the predominant symptoms in large bowel obstruction [12]. Only 25% of
patients with colonic lipoma develop symptoms [6]. Symptom
duration before intussusception may vary from 1 day to 7 years,
and the size of the lipoma is a predictor of symptomatology [6].
After intussusception, symptoms are specic to the intussusception
rather than the lipoma. Only about 10% of adult intussusception
present with the typical triad of abdominal pain, palpable mass
and bloody stool, with abdominal pain being the most common

symptom followed by nausea and vomiting, and bleeding per

rectum [7,13]. Symptom duration is usually longer in benign as
compared with malignant lesions, and in enteric as compared
with colonic lesions [14]. This variable presentation along with
the chronic indolent course of the disease contributes to the fact
that most cases are diagnosed at emergent laparotomy when bowel
ischemia supervenes. Preoperative diagnosis has been reported at
rates as low as 40.7% and 50% [1].
Abdominal CT is the most sensitive diagnostic modality with
reported accuracy ranging from 58% to 100% [1]. The characteristic target sign or the sausage-shaped soft tissue mass with
a layering effect is a classical nding. Mesenteric vessels within
the bowel lumen are also typically described. The CT can often
differentiate between lead point and non-lead point intussusceptions. In patients presenting with sub-acute or chronic large bowel
obstruction, exible lower gastrointestinal endoscopy is helpful in
conrming the diagnosis of intussusception, detecting its location,
diagnosing the underlying lesion (lead point), and may represent a
treatment option.
Adult intussusception is almost always treated surgically. There
is debate on whether reduction of the intussusception should be
attempted before resection. Reducing the intussusception before
resection caries the risk of disseminating malignant cells when an
underlying malignancy is suspected. On the other hand, the advantage of reduction, especially in the small bowel, is preservation of
considerable lengths of the bowel to prevent development of short
bowel syndrome. Several authors have suggested surgical resection
without reduction (en bloc resection) when the bowel is inamed,
ischemic or friable, or when the risk of malignancy is high [4,15,16].
Azar et al. suggested that surgical resection without reduction is
generally the preferred treatment in adults, as almost 50% of both
colonic and enteric intussusceptions are associated with malignancy [4,14]. However, reduction is acceptable in post-traumatic,
idiopathic, and benign lead point intussusceptions. While intussusception itself has good prognosis, the main prognostic factor
affecting the course of the disease is the nature of the causative
lesion. Mortality for adult intussusception increases from 8.7% for
the benign lesions to 52.4% for the malignant variety [7].
4. Conclusion
Sigmoidorectal intussusception in adults secondary to intramural lipoma is rare. Colonic lipoma may result in complete
obstruction despite the absence of some cardinal features of acute
intestinal obstruction. Colonic lipoma should be considered in the
differential diagnosis of adults with intussusception and high index
of suspicion for obstruction should be maintained especially when
the lipoma is >2 cm. Surgical reduction followed by sigmoid resection represents an excellent treatment modality in intussusception
secondary to colonic lipoma.
Conicts of interest
None.
Sources of funding
None.
Ethical Approval
Hurley Medical Center Scientic Review Committee was contacted and veried that IRB approval was not required for this case
report.

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M. Mohamed et al. / International Journal of Surgery Case Reports 10 (2015) 134137

Author contribution
All authors were involved in the preparation of this manuscript.
Mohamed Mohamed designed and performed all aspects of the
operation. Karim Elghawy assisted in data collection and drafting the manuscript. Donald Scholten, Kenneth Wilson and Michael
McCann made substantial edits and revisions to the drafted
manuscript. Michael McCann contributed to the design and provided overall supervision of the paper. All authors read and
approved this article.
Consent
Permission to release information, photographs or video tapes
was obtained from the patient for the purpose of publication of this
case report. The consent form number *001142* was signed by the
patient and the corresponding author, and is available for review
by the Editor-in-Chief of this journal upon request.
Guarantor
Mohamed Mohamed, MD.Michael McCann, DO.
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