Adult ileocolic intussusception caused by a terminal ileal lipoma: A case report.

Adult ileocolic intussusception due to a terminal ileal lipoma mimicking malignancy: a rare case report

Adult intussusception is uncommon and usually presents with nonspecific symptoms. Cross-sectional imaging is extremely important for diagnosis. In adults, a lead point is often present and indicates the underlying cause, which can be benign or malignant. Therefore, the primary treatment is surgical resection. Colonic lipoma, although rare, is a frequent benign lesion that leads to colocolic intussusception.This report describes a 42-year-old woman who presented with 12 days of intermittent abdominal pain and no other associated symptoms. After multiple emergency department (ED) visits, her symptoms were initially attributed to constipation, as physical examination revealed only mild right lower quadrant tenderness, routine blood tests were within normal range, and abdominal X-ray (AXR) showed stool loading in the right colon. Subsequent cross-sectional imaging revealed a colocolic intussusception caused by a 5 cm submucosal lipoma acting as the lead point. She underwent open segmental colectomy with a primary side-to-side stapled anastomosis and was discharged on postoperative day eight without complications. Histopathology confirmed the presence of a lipoma and an incidental serrated adenoma.This case highlights the diagnostic challenge and the importance of cross-sectional imaging in patients presenting with nonspecific abdominal pain. Intussusception should be considered in the differential diagnosis of adults with abdominal pain. Computed tomography (CT) is essential for timely diagnosis, and surgical resection remains the mainstay of treatment, particularly in colocolic involvement.

Intussusception in adults is rare and is often associated with a pathologic lead point. While colonic adenocarcinoma is a common cause, well-differentiated colonic neuroendocrine tumors are exceedingly rare. We present a unique case of an ileocolic intussusception due to a distal ascending colonic neuroendocrine tumor, emphasizing the diagnostic challenges and importance of prompt intervention. A 60-year-old male with a previous screening colonoscopy in June of 2022 presented to the Emergency Department with two days of cramping, right upper abdominal pain with associated nausea and two episodes of emesis. A Computed Tomography (CT) scan of the abdomen and pelvis revealed an ileocolic intussusception noted at the level of the hepatic flexure with a lead point. Emergent surgical intervention identified a mass in the distal ascending colon, and a right hemicolectomy with successful side-to-side functional end-to-end anastomosis was performed. Final pathology confirmed a well-differentiated stage III colonic neuroendocrine tumor. After a successful postoperative recovery, a full body Positron Emission Tomography (PET) scan was completed and resulted in no evidence of avid metastatic disease. The patient was placed in cancer remission. Intussusceptions in the adult population are uncommon, and the etiology typically involves a pathologic lead point causing intestinal invagination. In this case, prompt diagnosis and management resulted in successful health outcomes with reduced mortality and morbidity, as untreated intussusception can have devastating results. Given this patient's colonoscopy was approximately one year ago, the probability of a colonic neoplasm acting as the lead point was low. However, identification of the intussusception resulted in a timely and lifesaving emergent right hemicolectomy, as this stage III tumor has a five-year median survival rate of only 50% if left untreated.This case report highlights a rare case of adult ileocolic intussusception involving a lead point at the distal ascending colon identified as an uncommon, well-differentiated stage III neuroendocrine tumor. It showcases the importance of considering intussusception as a diagnosis when evaluating adults with abdominal pain for prompt and adequate intervention, especially when malignant lead points and bowel necrosis are suspected.

Rationale:Adult intussusception is rarely observed, accounting for about 5% of all cases of intussusception. Most ileal lipomas are asymptomatic and do not need any special treatment. Herein, we describe a case with ileocolic intussusception caused by ileal lipoma.Patient concerns:A 27-year-old woman complaints of intermittent abdominal pain for 10 days.Diagnosis:Abdominal computed tomography demonstrated ileocolic intussusception. Colonoscopy revealed a spherical polypoid lesion with surface capillary rising from the lateral wall of the ileum. A diagnosis of ileocolic intussusception was made.Interventions:The patient underwent primary resection of the intussuscepted intestine after which an end-to-end anastomosis was performed.Outcomes:Histopathology report confirmed a 4.5 cm × 3.5 cm lipoma in the terminal ileum. The patient was discharged on a postoperative day 9 without complications.Lessons:We describe the difficulties in diagnosis and treatment of this rare cause of intussusception and review the literature on adult intussusceptions. The ileal lipoma is a very rare cause of ileocolic intussusception. Abdominal CT and colonoscopy are important for the diagnosis of intussusception and abdominal lipomas. Surgical resection remains the treatment of choice.

Adult intussusception is rare, accounting for approximately 5%-16% of all cases. Unlike pediatric intussusception, which is predominantly idiopathic, most adult cases are associated with organic lesions, nearly half of which are malignant. Idiopathic intussusception without a lead point is uncommon but appears to be increasingly recognized. We report a case of idiopathic adult ileocolic intussusception that mimicked cecal carcinoma in imaging studies. A 63-year-old male with a history of gastric cancer recurrence presented with a 3-month history of abdominal pain. Contrast-enhanced computed tomography (CT) revealed circumferential thickening of the right colon, forming a "target sign," and invagination of the ileocecal region into the right colon, suggesting ileocolic intussusception. Colonoscopy identified a nodular lesion presumed to be cecal carcinoma; however, the biopsy did not provide a definitive diagnosis of malignancy. Preoperative 18F-fluorodeoxyglucose-positron emission tomography (18F-FDG-PET/CT) revealed high FDG uptake at the leading edge of the intussusception; however, no findings indicative of metastatic disease were observed. The patient underwent elective surgery, and a right colectomy with lymph node dissection was performed. However, the intussusception was found to have spontaneously resolved at laparotomy. Histopathological examination showed mild intramural congestion in the ileocecal valve. Postoperative imaging confirmed the absence of any lead point lesion, resulting in a final diagnosis of idiopathic intussusception. This case highlights the diagnostic limitations of CT and PET/CT in evaluating lead points in adult intussusception, as false-positive findings are common. Given the possibility of spontaneous resolution, a conservative approach, including repeat imaging immediately before surgery, may be suitable in select cases of adult intussusception.

Introduction: Intussusception is defined as telescoping or prolapsing of the proximal bowel segment into the distal segment. The mechanism is not fully understood in primary or idiopathic intussusception; however, secondary intussusception is believed to result from a lesion in the bowel wall that alters the peristaltic pattern of the bowel causing invagination. This is a very rare phenomenon. Case Report: A 40-year-old male with history of GERD, gastritis, cholecystectomy, and appendectomy presented to the emergency department with 1-year history of intermittent abdominal pain located in the mid-epigastric area described as squeezing and non-radiating pain, associated with bilious, non-bloody vomiting, and weight loss of 20 lbs for the past 3 months. The patient denies any hematemesis, diarrhea, constipation, hematochezia, or melena. Because of recent weight loss, CT with contrast was obtained, which revealed small bowel intussusception of 6 cm length without any obvious small bowel lesions or lead points causing the intussusception. He underwent exploratory laparotomy with segmental small bowel resection. Pathology of the resected bowel showed normal mucosa and muscular intestinal wall without any lead points or lesions. Discussion: Intussusception in adult patients represents 5% of all intussusceptions. This pathology can be explained 90% of the time to be due to an origination of lead point such as a carcinoma, polyp, diverticula, stenosis, or benign neoplasm. Thus, most surgeons agree that intussusceptions in adults require surgical resection due to intraluminal lesions as lead points, and therefore, its risk of malignancy. In adult patients, 90% of intussusceptions occur with a lesion of the intestinal wall or any irritant factor in its lumen that alters normal peristaltic activity, which serves as a trigger to start an intussusception of 1 bowel segment over another. In cases where no lead points are identified, intussusception may be due to submucosal bowel edema, fibrous adhesions, or dysrhythmic contractions. However, 8-20% of cases are idiopathic, without a lead point lesion. Transient non-obstructing intussusception without a lead point has been described in patients with celiac disease and Crohn’s disease, but is more frequently idiopathic and resolves spontaneously without any specific treatment. Conclusion: Intussusceptions in adults is a rare and challenging diagnosis. It is often initially missed or delayed due to its vague, non-specific symptoms. Abdominal CT is the most sensitive imaging modality, and can be helpful in distinguishing the presence or absence of a lead point. Treatment in adult intussusception is almost always by surgery due to frequent association with malignant organic lesions.

Intussusception is a recognized cause of bowel obstruction and is significantly more common in paediatric patients. Adult intussusception is rare and usually results from a predisposing factor in most patients. These factors may include benign lesions, malignant lesions, or bowel wall abnormalities such as inflammatory bowel disease. We report on a case of a patient who presented with recurrent colicky central abdominal pain, anorexia, vomiting with occasional constipation and diarrhoea for six months. She was assessed and investigated with abdominal USS and Computer Tomography (CT) Scan, which showed features of intussusception, with telescoping of the jejunum with proximal bowel distension suggesting bowel obstruction. The patient underwent emergency laparotomy and surgical resection, and histopathology confirmed the lead point as intraluminal lipoma.We present a case of jejuno-jejunal intussusception in an adult, which is not commonly seen. The history of recurrent colicky abdominal pain and CT abdomen, together with an abdominal ultrasound scan (USS), was important in establishing a preoperative diagnosis, and histology confirmed lipoma as a lead point. Despite the conservative approach described in the literature, surgery continues to be the only option in patients who are unstable with persistent colicky abdominal pain, vomiting, abdominal distension, and constipation; Surgery is advocated for all adult patients. Adult intussusception is not a common condition and can be difficult to diagnose, posing a diagnostic conundrum. Patients with intussusception may report a relatively long period of recurrent colicky abdominal pain that might worsen acutely following complete obstruction. Abdominal CT scan is a very useful investigation in the preoperative diagnosis of intussusception, with histopathological confirmation of lipoma as a lead point.

Abstract: Adult intussusception is a rare condition usually associated with a lead point. However, 8%–20% of cases are idiopathic. We describe here the case of a 56-year-old Nigerian male who presented to the accident and emergency unit with features of acute intestinal obstruction. The findings at laparotomy were ileocolic intussusception without a lead point. A segment of the terminal ileum was nonviable. A right hemicolectomy with ileocolic anastomosis was performed, and the resulting specimen sent for histologic examination which confirmed no extra- or intraluminal lesion. Two years of postoperative evaluation was normal. This report further reiterates the fact that adult intussusception could be idiopathic (without a lead point) and could present as acute intestinal obstruction. Early recognition is necessary to facilitate timely intervention before the onset of gangrene, so as to improve prognosis. Keywords: atypical presentation, adult, ileocolic, intussusception

Adult intussusception is a rare cause of intestinal obstruction characterized by the telescoping of one segment of the intestine into another. Unlike in children, adult intussusception accounts for a small proportion of intestinal obstructions and is usually associated with an identifiable cause, such as malignancy or polyps. We present a case of ileo-colic intussusception in an elderly female, confirmed on abdominal computed tomography (CT) imaging, and successfully treated with emergency laparotomy and segmental bowel resection. Histology identified a benign lipomatous polyp as the lead point for the intussusception. This case demonstrates that adult bowel intussusception presents with non-specific symptoms, and early detection through abdominal CT imaging is crucial. Surgeons should be aware of the potential association with underlying malignancy, particularly in elderly patients, and therefore segmental resection should follow strict oncological principles.

Background: Intussusception in adults is distinct from pediatric intussusception in many aspects. In contrast to intussusceptions in children, a demonstrable etiology is found in 70%-95% of the cases in the adult population, and approximately 40% of them are caused by primary or secondary malignant neoplasms. But lymphomas, as a cause of lead point in adult intussusception, are extremely rare and only less than 50 cases have been reported in the literature. Case Presentation: We are reporting a 44-year-old male who presented with a right iliac fossa mass and clinical features of intussusception and who was operated upon. Per-operative findings were consistent with ileocecal intussusception and a radical right hemicolectomy was conducted. Histopathological examination revealed it as a case of Difuse Large B Cell Lymphoma presenting as the lead point. This case is discussed because of the rarity of the disease and possible cure if diagnosed early and treated aggressively. Conclusion: Ileocolic intussusception is adults is usually caused by malignancy and mostly as adenocarcinoma. Non-Hodgkin lymphoma as a lead point is extremely rare and is usually a histologic surprise. However, a radical en mass resection without reduction is ideal in all forms of adult colocolic and ileocolic intussusception.

INTRODUCTION: Intussusception is a form of bowel obstruction defined as the telescoping of proximal segment of bowel into a distal segment. Intussusception in adults accounts for 5% of all cases and is usually secondary to a lead point such as a tumor or polyp. Intussusception in adults presents with vomiting, abdominal pain, hematochezia, or constipation. Cases where organic lesions act as the lead point present as a bowel obstruction. CT scan is diagnostic, which can identify location and presence of a lead point. Those with lead points can cause obstruction and ischemia- surgery is the treatment. Intussusception developing after an endoscopic procedure is extremely rare. In several cases there was a polypectomy performed and the subsequent intussusception was attributed to bowel edema acting as a lead point. All cases were treated with surgical intervention. CASE DESCRIPTION/METHODS: A 54-year-old female patient with a history of diabetes presented to the ED with worsening colicky abdominal pain starting four hours after a colonoscopy with polpectomy in the transvsere colon was performed. She also experienced red mucus in her stools. Her vital signs were within normal limits. On exam, she had a non-distended abdomen, with mild tenderness over the RUQ without any palpable masses. Her blood work was significant for a white count of 13 with a normal metabolic profile and lactate. The patient had an abdominal X- ray and CT of the abdomen which showed a transverse colo-colonic intussusception with partial obstruction. The patient was seen by the surgical team who opted for a conservative management with IV fluids and nil per os. Her symptoms rapidly improved the next day. She was started on a liquid diet which was advanced without complications. She was discharged on the third day after a normal bowel movement. An MRI two months after discharge was unremarkable. DISCUSSION: Intussusception with colonoscopy as an etiology is very uncommon. In our patient, polypectomy in the setting of colitis likely contributed to her development of an intussusception and partial bowel obstruction. There are no standard guidelines for management. In all colonoscopy-related cases cited, surgical interventions were pursued. Conservative management was pursued for our patient who had complete resolution of her symptoms. This report demonstrates that in non-malignant intussusception cases a conservative approach at first, with surgery reserved for patients with worsening symptoms, is practical.Figure 1.: Intussusception shown on abdominal CT (orange arrow).Figure 2.: Followup MRI showing resolution of intussusception (orange arrow).

Intussusception in adults is an unusual finding and is commonly associated with benign or malignant mass as the leading point. A preoperative diagnosis on imaging is helpful in diagnosing intussusception along with pathology causing it and aids in further management. We present a case of ileocolic intussusception with lipoma as the lead point: classic ultrasonography and CT imaging findings are described with its postoperative confirmation.

Intussusception in adults is an uncommon cause of intestinal obstruction and is usually associated with an underlying structural lesion, unlike pediatric cases. In most adult patients, a pathological lead point is identified, frequently neoplastic in origin, making surgical management the standard treatment. We present the case of a 66-year-old man with a history of type 2 diabetes mellitus who presented with colicky abdominal pain, vomiting, and hematochezia. Physical examination revealed abdominal distension, tympany, diffuse tenderness, rebound tenderness, and hyperactive bowel sounds. Computed tomography demonstrated dilated small bowel loops with a transition zone and findings suggestive of ileocolic intussusception causing mechanical bowel obstruction. An exploratory laparotomy was performed, revealing ileocolic intussusception associated with two lesions in the terminal ileum located 15 and 25 cm from the ileocecal valve. Segmental resection of 30 cm of the terminal ileum with distal closure, terminal ileostomy, and incidental appendectomy was carried out. Histopathological examination reported an inflammatory fibroid polyp measuring 4 × 2.3 cm associated with ulcerated ischemic ileitis, without compromise of surgical margins. Adult intussusception should be considered secondary to an organic lesion until proven otherwise. Prompt diagnosis with computed tomography and early surgical intervention are essential to prevent ischemic complications. Although rare, inflammatory fibroid polyps may act as a pathological lead point for intussusception and bowel obstruction.

Adult ileocolic intussusception is almost always associated with a pathological lead point. We present a 29-year-old male with autism spectrum disorder (ASD) who attended with a one-week history of colicky right iliac fossa pain and loose stools. Communication difficulties related to ASD delayed a clear clinical history. Abdominal ultrasonography demonstrated a 7.0 × 6.0 cm target sign in the subhepatic region. Contrast-enhanced computed tomography confirmed ileocolic intussusception extending to the hepatic flexure, with a heterogeneously enhancing 6.6 × 4 × 3.4 cm lead-point mass. Diagnostic laparoscopy was converted to open right hemicolectomy with ileocolic anastomosis. Histopathology revealed B-cell non-Hodgkin lymphoma, confirmed by immunohistochemistry (CD20+, BCL2+, BCL6+, MUM1+, and c-MYC+). The patient was referred for oncological management and was well at one-month review. This case highlights that adult intussusception caused by lymphoma can present insidiously, particularly in patients with impaired communication, and that early cross-sectional imaging and prompt surgical resection are essential.

Intussusception is a rare cause of adult intestinal obstruction and unlike in children, adult intussusception is commonly caused by a lead point, requiring surgical intervention in most cases. Hamartomatous polyp is a non-neoplastic growth of tissue containing mature cells, distributed in an abnormal manner. It is often associated with intestinal polyposis syndromes such as Peutz-Jeghers syndrome and Juvenile polyposis. In the current case, we report an extremely rare case of ileo-colic intussusception secondary to a lead point of an isolated ileal hamartomatous polyp in an elderly gentleman with Neurofibromatosis type-1. Patient was successfully treated with ileo-colic resection involving the intussuscepted segment of bowel. There was an incidental finding of a nodule in the appendix and the histology confirmed this as a neurofibroma. Post-operative recovery of the patient was unremarkable.