An Unusual Cause of Abdominal Pain: A Telescopic View

Abstract

1642_A Figure 1. Abdominal CT scan showing transverse colon invaginating into descending colon (arrow)1642_B Figure 2. Endoscopic view of rounded, ulcerated mass as lead point lesionIntroduction: Intussusception is well studied in the pediatric population but accounts for only about 1% of bowel obstructions in the adult population. Adult intussusception involving only the colon is even more rare. Case Description: A 35-year-old female presented to the emergency department with waxing and waning lower abdominal pain over a several week period. Her symptoms were initially thought to be gynecologic in origin but a transvaginal ultrasound was normal and she was discharged with outpatient follow up. She returned two weeks later with sudden worsening of the abdominal pain with associated vomiting, chills, and hematochezia. Examination revealed normal vital signs and a tender left hemiabdomen without peritoneal signs. Biochemical markers were essentially normal. Abdominal CT scan showed colocolonic intussusception involving the distal transverse and proximal descending colon with a large fat density mass as the lead point. Surgical consultation was obtained and colonoscopic exam was requested to evaluate for malignancy. Colonoscopy revealed a rounded, ulcerated, friable mass 50 cm from the anal verge that was nearly occluding the lumen, with inability to reduce the invaginated colon. Biopsy specimens resulted as fragments of ischemic/necrotic colonic mucosa with overlying acute inflammatory exudate without evidence of a neoplastic process. Symptoms persisted and the patient underwent a laparoscopic partial colectomy with primary anastomosis. Gross examination of the surgical specimen revealed an intussuscepted colon with a 6cm sessile mass containing adipose tissue with associated mucosal surface ulceration. Lipoma was confirmed on histologic examination. The patient recovered uneventfully and was discharged on post-operative day 3. Discussion: Colocolonic intussusception in adults is a rare entity and caused by benign lesions in less than 25% of these cases. In the stable patient, attempting endoscopic reduction of the intussusceptum is gaining traction in the medical literature. Colonoscopy can be used to definitively diagnose the lead point lesion and preserve viability of the effected bowel. Although our case was unsuccessful in such an attempt, colonoscopy should be considered in the future for diagnosis and reduction in cases of colocolonic intussusception.1642_C Figure 3. Gross specimen revealing in tact intussusception with large, sessile lipoma which was confirmed histologically