Intussusception in Adults-Submucosal Lipoma at Transverse colon-A rare cause

1. Lipoma at the Transverse Colon:
A rare Cause for Intussusception
in Adults
Dr. Santosh Atreya
MD Residency Department of Radiology &
Imaging
Phase-B
BSMMU

2. Topics To Be Discussed Today
• Introduction of Colonic Lipoma
• Introduction of intussusception
• Etiology
• Epidemiology
• Clinical presentation
• Radiological features
• Management

3. COLONIC LIPOMA
• Colonic Lipoma
• Rare non-epithelial neoplasms
• First described by bauer in 1757
• Incidence : 0.2 % to 4.4 %.
• More common in elderly women
• Mainly in the cecum and ascending
colon.
• Most common sub mucosal
tumour in colon
• Most of them are small in size,
solitary and asymptomatic.
• 30 % of them reach 2 cm

4. • Adult intussusception is thought to be rare,
accounting for an estimated 5% of all
intussusceptions and only 1% of small bowel
obstructions.

5. Intussusception
• Agha,AJR 1986;146.
-25 adult intussusceptions
-a causative factor was identified in 23
patients(92%)
-other 2 cases were considered indeterminate

6. • Ekran,Int J Colorectal Dis 2005;20
-13 adult Intussusceptions
-a pathologic cause for the Intussusception was
identified in 92.3%
-only one case was considered to be idiopathic

7. INTUSSUSCEPTION
• Describes in which one segment of the
intestine telescopes or invaginates into the
lumen of an adjacent segment of intestine.
•It is common in children & an
important cause of an acute
abdomen .
•Rare in adult population
where it is usually caused by a
focal lesion acting as a lead
point.

8. Intussuscpetion
Without a
leading point
With aleading
point
ymphoid

9. Etiology
Children Adults
Spontaneous: (without
anatomical leading point) in90%
of cases:
. Leading point(90%):
•Tumor:
Usually benign in smallintestine
& malignant in largeintestine.
•Polyp,
•Ulcer,
•Foreign body.

10. Epidemiology
• The vast majority of intussusceptions occur in
children (95%), usually after the first three
months of life most frequently seen in
children under 2 years of age.

11. • In adults,Secondary to malignant neoplasms
in about half of the cases
• Most neoplasms-related cases are due to
Adenocarcinoma
GIST
Metastatic melanomas
Lipoma-Rare

12. Adult Intussusception
• Pathogenesis:
• The tumour may act as a
foreign body
provoke abnormal
peristaltic movement
leads to telescoping of
one bowel segment into
the dilated distal part.
The trapped section of bowel may have cut off
blood supply
Resulting ischaemia - Mucosa sensitive to
ischaemia-Responds sloughing off into the gut

13. LOCATION
• In adults no pattern of distribution is present
as such as in the vast majority of cases a lead
point lesion is present, and thus the location
will depend on the location of that lesion. In
children there is a strong predilection for the
ileocolic region:

14. In Children
Commences in the ileum as the result of the lymphoid tissue
& tends to be associated with mesenteric adenitis. The
enlarged lymphatic patches are forced into ileum by
peristaltic movement & acting as a tumour, one part of the
ileum is pulled into the other & finally pulled into the colon.

15. Location in children
• ileocolic: most common (75-
95%), presumably due to the
abundance of lymphoid tissue
related to the terminal ileum
and the anatomy of the
ileocaecal region
• ileoileocolic: second most
common
• ileoileal and
colocolic: uncommon
• gastric intussusception: rare, but
documented

16. Clinical Presentation

17. C.P
Children(6M-2Y) Adults
Abrupt onset of violent
crampyabdominalpain.
Recurrentabdominal
pain.
Vomiting.
Redcurrantjelly stool. Bloodystool.
PalpableAbdominal
mass.
More commoningirls
3:1
Palpableabdominal
mass.

18. Types
•Enteroenteric involving only the small bowel
•Colocolic involving only the large bowel
•Ileocolic involving the terminal ileum and
ascending colon

19. Diagnosis
A definite diagnosis requires confirmation by
imaging modalities.

20. • In early stages may be
unremarkable. However in
advanced stages it may show
signs of bowel obstruction.
• Meniscussign:
• Crescent of gaswithin colonic
lumenthat outlines the apexof
intussusceptum-More frequently
identified in right
hypochondrium.
• Little air in smallintestine.
Plain Radiograph
Supine film.
There are multiple gas-filled
loops of slightly dilated small bowel. In addition,
there is a soft-tissue mass
in the right iliac fossa (arrow). A 5-month-old child
with mesenteric adenitis

21. Meniscus
sign

25. Ultrasound
• Ultrasound signs
include:
• Target sign (also
known as the
Doughnut sign)
• Pseudokidney sign
• crescent in a
Doughnut sign

26. Longitudinal ultrasound images
demonstrate bowel intussusception
imitating the adjacent normal kidney. This
is termed the “Pseudokidney” sign.

27. • However this
investigation is performer
dependant and at times
may be missed by an
inexperienced sonologist
• Should always be done
by a radiologist

28. FLUOROSCOPY
• A contrast enema: Gold
standard, demonstrating the
intussusception as an
occluding mass prolapsing into
the lumen, giving the "coiled
spring” appearance (barium in
the lumen of the
intussusceptum and in the
intraluminal space).
• Contraindication Perforation,

29. • In children both diagnostic (the gold standard
in the diagnosis of intussusception) and
therapeutic.

30. CT
• CT has become the
modality of choice for
assessment of acute
abdomen in adults.
• The appearance on CT is
characteristic and depends
on the imaging plane
• Best known is the so-called
bowel-within-bowel
configuration when
imaged at right angles to
the lumen, and a soft
tissue sausage when
imaged longitudinally. 23 years old women with 2 weeks history of
intermittent abdominal pain, minimal
diarrhoea, no nausea or vomiting.

31. MRI
• Recent developments in MRI with ultrafast multiplanar
techniques now allow for rapid evaluation of the
bowel, particularly in cases of small bowel obstruction.
• Multiplanar HASTE (half-fourier single shot turbo spin
echo) imaging to be particularly useful in the evaluation
of intussusception. This sequence is relatively motion-
insensitive and has the ability to obtain heavily T2-
weighted data within a single breath-hold.
It can
• demonstrate intussusception clearly, as there is high
contrast resolution between the high signal of
intraluminal fluid and the intermediate to low

32. • signal of the bowel
wall.
• MRI’s multiplanar
ability allows precise
localization of the
segment of bowel
involved . An
underlying lead
point may also be
identified.
Axial multiplanar HASTE (half-fourier spin turbo echo, ) imaging
showing intussusception in the bowel adjacent to the right kidney. (b)
and (c)
Coronal HASTE images showing the target (arrow) and
sausage shapes of the intussusception. A lead point was
not identified.The diagnosis of myofibroblastic tumour was made at
surgery.

33. Treatment and prognosis
laparotomy is usually
required, especially as in most
cases a lead point requiring
treatment is present.
In children, intussusception reduction
can be achieved without recourse to
surgery in most cases. Using a water-
soluble medium or air introduced via
a rectal catheter.

34. Take Home Messages
• Common in children. Rare in adults (Lipoma causing
intussusception is more rare : 0.2 % to 4.4 %. )
• In adults almost half of the cases associated with lead
point.
• In children both diagnosis & treatment falls under
Radiology whereas in adults surgery is indicated for
treatment.
• Unlike children in adults any site may be involved,
depending upon the site of lead point.
• Various important radiological signs-Should be
remembered.