A Sigmoid Lipoma Causing Colo-Colic Intussusception in an Elderly Patient

Dear Editor, We have read with interest the article titled "Intestinal Lipoma Causing Intussusception in an Adult – A Case Report" by Vaishali Pol, Sayali Deshmukh, et al. Medical Journal of Dr. D.Y. Patil Vidyapeeth 16 (4):p 631-633, Jul–Aug 2023.[1] Although relatively common in childhood, intussusception causing intestinal obstruction is a rare entity in adults. Approximately 5 percent of all intussusceptions are seen in adults, but they account for only 1 percent of adult intestinal obstructions. Most adult instances are caused by structural abnormalities, with only a small percentage being idiopathic.[2] Lipomas of the intestine are rare benign mesenchymal tumors containing adipose tissue. They usually present as sessile polypoidal masses and may serve as points of intussusception. They are very rarely pedunculated.[3] We present a case of a colonic lipoma with colo-colic intussusception. A 75-year-old male, hypertensive on regular antihypertensives, presented with complaints of colicky pain in the left lower quadrant of the abdomen for 1 month. He also complained of intermittent constipation for the past 3 months. The patient denied a history of vomiting, hematochezia, melena, abdominal distention, weight loss, or fever. Clinically, he was hemodynamically stable, without any pallor, peripheral lymphadenopathy, or pedal edema. Abdominal examination was unremarkable. Laboratory investigations revealed mild microcytic hypochromic anemia (hemoglobin (Hb): 10.8 g/dL). A contrast-enhanced computerized tomography (CECT) of the abdomen revealed a large round to oval non-enhancing fat density lesion of size 76 mm × 58 mm × 61 mm within the submucosal plane of the sigmoid colon with a few homogeneously enhancing septae and minimal fat stranding within which was suggestive of a large lipoma [Figure 1]. The mass was acting as a lead point causing colo-colonic intussusception with invagination of descending colon into the sigmoid colon for an extent of about 72 mm.Figure 1: A contrast-enhanced computerized tomography (CECT) of the abdomen showing a large round to oval non-enhancing fat density lesion of size 76 mm × 58 mm × 61 mm within the submucosal plane of the sigmoid colon with a few homogeneously enhancing septae and minimal fat stranding within which was suggestive of a large lipomaColonoscopy revealed a large polypoidal lesion at 40 cm from the anal verge with ulceration at the tip [Figure 2]. The scope was not negotiable beyond the polyp. The patient underwent laparotomy, the intussusception was reduced, and a left sigmoid colectomy was performed. At 6 months post-op follow-up, the patient was asymptomatic.Figure 2: Colonoscopy imaging showing a large polypoidal lesion at 40 cm from the anal verge with ulceration at the tipIn adults, malignant lesions account for 65% of all cases of intussusception.[4] In the small bowel, metastatic melanoma is the most common malignancy causing intussusception. In the colon, adenocarcinoma accounts for most cases. Colonic lipomas were first described by Bauer in 1757. Lipomas of the gastrointestinal tract (GIT) are more common in the colon (65%-75%) and small intestine (20%-25%) and are rarely seen in the stomach and esophagus.[2] Smaller lipomas are generally asymptomatic while larger lipomas may present with obstruction, abdominal pain, intussusception, or hemorrhage. Intussusception occurs when the intraluminal lesion is dragged forward during normal peristalsis, resulting in the proximal bowel telescoping into a segment of the distal colon. CT is often the first step of diagnosis (sensitivity from 71.4% to 87.5%, and specificity, in adults, close to 100%) followed by colonoscopy which allows for direct visualization and possible resection via snare. Management includes segmental resection with anastomosis to achieve continuity of the GIT. If there is evidence of irreversible intestinal ischemia, inflammation, or malignancy, reduction should not be carried out.[2] Large benign tumors causing intussusception in the elderly are very rare but have been reported in the literature. They should be considered as a differential in elderly patients presenting with intussusception or signs of intestinal obstruction. Data availability statement Data will be made available on request by the corresponding author. Author's contribution Dr. Prashant Gopal: Formal analysis, software, validation, writing-review, and editing; Dr. Debabrata Banerjee: Formal analysis, investigation, data curation, validation, writing-review, and editing; Dr. Indrakeela Girish: Conceptualization, methodology; Dr. Sanjay M. Khaladkar: Formal analysis, software, validation. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.