(Radiology. 2000;216:727-730.)
© RSNA, 2000
Case 26: Jejunojejunal Intussusception Secondary to a Lipoma1
Gerald J. Ross, MD and
Venkata Amilineni, MD
1 From the Department of Radiology, St Francis Medical Center, 400 45th St, Pittsburgh, PA 15201-1198. Received February 19, 1999; revision requested April 23; revision received May 18; accepted June 2. Address correspondence to G.J.R. (e-mail: gerald_ross@Yahoo.com).
Index terms: Diagnosis Please • Intestines, CT, 74.12112 • Intussusception, 74.73 • Lipoma and lipomatosis, 74.315
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HISTORY
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An 80-year-old woman with a history of carcinoma of the breast was admitted to the hospital for severe, colicky upper abdominal pain. She had experienced episodes of similar pain in the past. Her physical examination and laboratory test results were unremarkable.
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IMAGING FINDINGS
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Figure 1 shows the classic target appearance of an intussusception in which the inner central area represents the invaginated intussusceptum, which is surrounded by its mesenteric fat and associated vasculature, all of which are surrounded by the thick-walled intussuscipiens. The intussusceptum contained orally administered contrast material and a small amount of gas. An image (Fig 2) obtained slightly caudad to Figure 1 shows a round mass of fat attenuation representing a lipoma, the lead point of the intussusception. The patient underwent laparotomy and resection of the involved segment of jejunum. The gross pathologic specimen showed a lobulated, submucosal lipoma without overlying ulceration of the mucosa (Fig 3).
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Figure 1. Jejunojejunal intussusception secondary to a lipoma. A transverse contrast material-enhanced computed tomographic (CT) scan of the abdomen shows the typical multilayered appearance of an intussusception. The intussusceptum containing contrast material and gas (black arrow), with accompanying mesenteric fat and mesenteric blood vessels (arrowhead), is surrounded by the thick-walled intussuscipiens (white arrow).
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DISCUSSION
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The CT findings in intussusception are usually pathognomonic (1). The CT features include: (a) A targetlike or sausagelike mass, depending on the angle of the beam relative to the intussusception, in which the inner central area represents the invaginated intussusceptum that is surrounded by its mesenteric fat and associated vasculature, all of which are surrounded by the thick-walled intussuscipiens (2). (b) Oral contrast material trapped between the opposing walls of the intussusceptum and intussuscipiens. (c) A soft-tissue mass secondary to the intussusception, possibly with the accompanying lead point, telescoping into the intussuscipiens (1–3). If blood supply is compromised, bowel-wall thickening, as seen in this case, or intramural air may be seen (4).
Although intussusception can be diagnosed by means of CT in nearly all cases, it is rare to be able to demonstrate the lead point preoperatively. A lipoma can be diagnosed if a smooth mass of fat attenuation (-50 to -100 HU) is identified within the lumen of the intussuscipiens (5).
Ultrasonography also has depicted the typical multilayered appearance consisting of the alternating hyperechoic and hypoechoic concentric rings that represent alternating layers of mucosa, bowel wall, and mesenteric fat in cross section (6).
Abdominal conventional radiographs may show dilated bowel, a paucity of bowel gas in the right lower quadrant, or a soft-tissue mass that produces a concave defect in the air column of the colon (in an ileocolic intussusception) (7,8).
If the colon is involved, barium enema examination may show obstruction to retrograde flow secondary to a smooth filling defect that represents the leading edge of the intussuscepted bowel or a "coiled-spring" appearance if contrast material outlines the invaginated intussusceptum (8). An antegrade barium examination in an intussusception involving small bowel will show a beaklike termination at the point of intussusception when there is complete obstruction. In incomplete obstruction, a coiled-spring appearance in which barium is trapped between the intussusceptum and intussuscipiens is seen.
Intussusception is usually a disease of children 6 months to 4 years old in which the ileum (intussusceptum) telescopes into the colon (intussuscipiens)—an ileocolic intussusception. In this age group, there is usually no lead point, and the cause is thought to be a viral infection that results in either enlarged ileocolic lymph nodes or bowel-wall inflammation (7). Enteroenteric intussusceptions are rare in children (9).
Intussusceptions are much less common in adults, who account for 10% of all intussusceptions, and unlike in children, a lead point is usually found (2,5). In adults, intussusceptions may be ileocolic, colocolic, enteroenteric, or jejunogastric, and there is no anatomic predilection (5,7). The lead points of adult intussusceptions that involve the colon are usually malignant (carcinoma, lymphoma), whereas those that involve the small bowel tend to be benign (lipoma, polyp, Meckel diverticulum, sprue, or from lymphoid hyperplasia secondary to viral infection) (5,10).
The clinical presentation of patients with intussusception also differs in these two age groups. Children present acutely with colicky abdominal pain, vomiting, bloody stools that look like currant jelly, and often a palpable mass (2,9). Symptoms in adults tend to be more chronic or intermittent and include pain, constipation, weight loss, or a palpable abdominal mass at physical examination.
Lipomas can occur in either the large or small bowel. They are usually submucosal and do not produce symptoms until they reach approximately 4 cm. Lipomas may result in chronic blood loss due to ulceration of the overlying mucosa in addition to intussusception (11).
The patient’s history of colicky abdominal pain was almost certainly secondary to episodes of intermittent intussusception. Figure 1 is pathognomonic for an intussusception. Likewise, the demonstration of the intraluminal mass of fat attenuation in Figure 2 is characteristic of a lipoma; and when interpreted in conjunction with Figure 1, it would lead one to conclude that the lipoma is the lead point for the intussusception. The intussusception reduced during surgery and there was no evidence of bowel ischemia. The patient remained asymptomatic 2 months following surgery.
Our congratulations to the 197 individuals who submitted the most likely diagnosis (jejunojejunal intussusception secondary to a lipoma) for Diagnosis Please, Case 26. Credit was given only if intussusception due to lipoma was mentioned. The names and locations of the individuals, as submitted, are as follows:
- Hisashi Abe, Osaka, Japan
- Gholamali Afshang, MD, Tinley Park, Ill
- Julio Almeida Llanos, Rosario, Argentina
- Nabil Ammouri, MD, Zahle, Lebanon
- Roger Antonelli, MD, Dayton, Ohio
- Juan Arenas, Spain
- Jonathan R. Arnow, MD, Lexington, Mass
- Lionel Arrivé, Paris, France
- Leon Axel, PhD, MD, Philadelphia, Pa
- Dean Baird, MD, Arlington, Va
- Edward L. Baker, MD, San Francisco, Calif
- Tamra K. Baldauf, MD, Las Vegas, Nev
- Ken Baliga, Rockford, Ill
- Julie Barudin, MD, Hackensack, NJ
- Dr Monia Ben Messaoud, Tunis, Tunisia
- James Bezreh, MD, Needham, Mass
- Barbara Biber, MD, Portland, Me
- Grazia Bitti, Cagliari, Italy
- Miguel Blanco Ulla, MD, Santiago de Compostela, Spain
- Frank S. Bonelli, MD, PhD, Rockford, Ill
- Francis M. Bradley, MD, Boston, Mass
- Adrian Brady, FFRRCSI, FRCR, Cork, Ireland
- Giuseppe Brancatelli, MD, Palermo, Italy
- Michael R. Brand, MD, Fullerton, Calif
- Eric Bressler, Minnetonka, Minn
- Doug Brown, MD, Durham, NC
- Douglas Brown, MD, Virginia Beach, Va
- Michael P. Buetow, MD, Okemos, Mich
- Charles H. Bush, MD, Gainesville, Fla
- Alfredo E. Buzzi, MD, Buenos Aires, Argentina
- Ramón Carabajal, MD, Tucuman, Argentina
- Rich Cardella, MD, Cincinnati, Ohio
- Ted Cardoso, Tampa, Fla
- Linda Casey, MD, Albuquerque, NM
- Christophe J. Chagnaud, MD, Marseille, France
- Hearns Charles, MD, New York, NY
- Chris E. Chernesky, MD, Springfield, Mo
- Daryl Chinn, MD, Newport Beach, Calif
- Pablo Cikman, MD, Córdoba, Argentina
- Brad Cohen, MD, West Palm Beach, Fla
- Martin Cohen, MD, Westlake Village, Calif
- Jay M. Colby, MD, Worcester, Mass
- Libby Cone, MD, Philadelphia, Pa
- Y-S Cordoliani, MD, Paris, France
- Harrell Cox, Scottsboro, Ala
- Steve Cremer, MD, Moline, Ill
- Steve Cunat, MD, Hunt Valley, Md
- Abe Dachman, Chicago, Ill
- M. G. de Baets, MD, Lugano, Switzerland
- M. C. de Jonge, MD, Amsterdam, the Netherlands
- J. F. K. de Villiers, Gisborne, New Zealand
- Gautam Dehadrai, MD, Chicago, Ill
- Kemal Demir, MD,
stanbul, Turkey
- Seyed A. Emamian, MD, PhD, Washington, DC
- Martin R. Engel, MD, Lihue, Hawaii
- Keith D. Epperson, MD, Milwaukee, Wis
- Dr Mario Finazzo, Palermo, Italy
- Fritz Flueckiger, MD, Graz, Austria
- Anthony M. Foti, MD, Buffalo, NY
- Juan Francisco Garcia, MD, Monterrey, Mexico
- Richard Friedland, Poughkeepsie, NY
- Akira Fujikawa, Tokyo, Japan
- Teresa Adriana Garcia, MD, Buenos Aires, Argentina
- Douglas Gardner, MD, Windsor, Ontario, Canada
- Glenn Garneys, MD, Peterborough, Ontario, Canada
- Dietrich Gerhardt, Waterloo, Iowa
- Brad Gluck, MD, Southampton, NY
- Burton Gold, MD, Mineola, NY
- W. Zev Goldstein, MD, Poughkeepsie, NY
- Philip Goodman, MD, Lexington, Ky
- Roy Gottlieb, DO, Oak Park, Calif
- Herbert F. Gramm, Boston, Mass
- Neil B. Green, MD, Fredericksburg, Va
- Flavius Guglielmo, MD, Basking Ridge, NJ
- Adam Guttentag, MD, Wynnewood, Pa
- Linda B. Haramati, Bronx, NY
- Yasuhiro Hata, Osaka, Japan
- Dr Dargouth Hatem, Tunis, Tunisia
- Maureen Heldmann, MD, Shreveport, La
- Howard T. Heller, MD, Garden City, NY
- Helen T. Ho, MD, Chicago, Ill
- Mindy M. Horrow, MD, Philadelphia, Pa
- Peter Ingle, MD, Wahroonga, Australia
- Jose M. Irizarry, MD, Weston, Fla
- Gary Israel, MD, New York, NY
- Dr Manoj Jain, Chandigarh, India
- Hirotsugu Kado, Fukui, Japan
- Sanjeeva Prasad Kalva, MD, Coimbatore, Tamilnadu, India
- Masayuki Kanematsu, MD, Gifu, Japan
- Barry J. Kanner, MD, New York, NY
- Robert Y. Kanterman, MD, St Louis, Mo
- Ryuji Katada, Sapporo, Japan
- Douglas S. Katz, MD, Mineola, NY
- Eung-Yeop Kim, MD, Wonju city, Kangwondo, South Korea
- Eric Kinder, MD, Stanford, Calif
- Mitchell A. Klein, MD, Milwaukee, Wis
- Arlene Klink, MD, Garden Grove, Calif
- Richard Krauthamer, MD, Rolling Hills, Calif
- Jeffrey Kuo, San Francisco, Calif
- David Kurti, MD, Naperville, Ill
- Stephanos Lachanis, MD, Athens, Greece
- John Lai, Calgary, Alberta, Canada
- Alan Laorr, MD, Eden Prairie, Minn
- Soon Jin Lee, MD, Seoul, Korea
- Anna S. Lev-Toaff, MD, Philadelphia, Pa
- J. Llauger, MD, Barcelona, Spain
- Eugene Long, Lagrange, Ga
- Goetz Lutterbey, MD, Bad Neuenahr, Germany
- Antonio Jose Madureira, MD, Porto, Portugal
- Yoji Maetani, Kyoto, Japan
- Ahmed-Emad Mahfouz, MD, Dammam, Saudi Arabia
- Stephen Manghisi, MD, Closter, NJ
- N. B. S. Mani, MD, Chandigarh, India
- Kathlyn Marsot Dupuch, Paris, France
- Michael B. Martin, MD, Austin, Tex
- Antonio Medina Benítez, Granada, Spain
- Elcy Medina, Medellín, Colombia
- Richard J. Meli, Atlanta, Ga
- Luis Méndez Uriburu, MD, Tucuman, Argentina
- Edward Menges, MD, Aptos, Calif
- Michael Merport, MD, Providence, RI
- Harlan D. Meyer, MD, Bexley, Ohio
- Manabu Minami, MD, Tokyo, Japan
- Robert E. Mindelzun, MD, Palo Alto, Calif
- Dr Roberto Miranda, Santiago, Chile
- Hidetoshi Miyake, MD, Oita, Japan
- Sergio J. Moguillansky, MD, Rio Negro, Argentina
- Eduardo Mondello, Buenos Aires, Argentina
- Mihail Motateanu, MD, Sierre, Switzerland
- Renato Moura Ribeiro, Sao Paulo, Brazil
- Michael Myers, MD, San Jose, Calif
- Carlos J. Nassar, Humacao, Puerto Rico
- Al Nizzero, MD, Sudbury, Ontario, Canada
- Sanford M. Ornstein, MD, Phoenix, Ariz
- David M. Panicek, MD, New York, NY
- Amir Belisario Perez Lanz, MD, Villahermosa, Tab., Mexico
- Alex Petersen, MD, Newcastle, Australia
- Carlo L. E. Petralli, MD, Bruderholz, Switzerland
- Benedito Pinheiro de Abreu Neto, São Paulo, Brazil
- Rubem Pochaczevsky, Bronx, NY
- Suwalee Pojchamarnwiputh, MD, Chiang Mai, Thailand
- R. Prashant, Ahmedabad, India
- Shawn P. Quillin, MD, Charlotte, NC
- Danny Rappaport, Toronto, Ontario, Canada
- Enrique Remartinez Escobar, MD, Melilla, Spain
- Hyunchul Rhim, MD, Seoul, South Korea
- Randall Rhodes, MD, Rockford, Ill
- Javier Rodriguez Lucero, MD, Rosario, Argentina
- Herbert Rosenthal, MD, Hannover, Germany
- Dan Rudensky, MD, Philadelphia, Pa
- Hun Kyu Ryeom, Taegu, Korea
- Julio Saenz de Ormijana, MD, Vitoria, Spain
- Sinan Sahin, MD, Istanbul, Turkey
- Mourad Said, MD, Monastir, Tunisia
- Paulo C. Sanvitto, Porto Alegre, Brazil
- Pierre Jean Sauvage, MD, Mâcon, France
- Pierre Schmit, l’Hay les Roses, France
- Steven M. Schultz, MD, Ft Worth, Tex
- Joel M. Schwartz, MD, Nyack, NY
- Anthony J. Scuderi, MD, Johnstown, Pa
- Raymond Selouan, Beirut, Lebanon
- Pranav N. Shah, MD, Wyomissing, Pa
- Matt Shapiro, MD, Lowell, Mass
- Aaron Shiloh, MD, Philadelphia, Pa
- Yoshihisa Shimanuki, MD, Sendai, Japan
- Taro Shimono, MD, Kyoto, Japan
- Tae Beom Shin, MD, Jung Gu, South Korea
- Marc Silver, Blue Bell, Pa
- Paolo Siotto, MD, Cagliari, Italy
- Stephen Skehan, MB, Cambridge, England
- Eric D. Smith, MD, San Diego, Calif
- Dr Juan Carlos Spina Ramos, Buenos Aires, Argentina
- Juan Carlos Spina, MD, Buenos Aires, Argentina
- Paul Stark, MD, La Jolla, Calif
- Michael S. Stecker, MD, Carmel, Ind
- Jeffrey Y. Sue, MD, Honolulu, Hawaii
- Denis Tack, MD, Charleroi, Belgium
- J. Takasugi, Mercer Island, Wash
- Toshiaki Takeda, Tokyo, Japan
- Douglas L. Teich, MD, Brookline, Mass
- Marie-Claude Thériault, MD, St-Georges, Québec, Canada
- Jeffrey S. Unger, MD, Warrensville Heights, Ohio
- Carlos Valls, MD, Barcelona, Spain
- Philippe Vanlede, MD, Izegem, Belgium
- Angelo Vanzulli, MD, Milan, Italy
- Dr Mario Vigo, Italy
- Kai Vilanova Busquets, Girona, Spain
- Christopher Vittore, MD, Rockford, Ill
- Mariano Volpacchio, MD, Buenos Aires, Argentina
- Jeff West, MD, Jacksonville, Fla
- Richard Whitehead, MD, Chestnut Hill, Mass
- Edward Williams, FRCR, Grand Cayman, Cayman Islands, British West Indies
- Neda Yagan, MD, New York, NY
- Seongjun Yang, Seoul, Korea
- Joe Yut, Olathe, Kansas
- Jeffrey H. Zapolsky, MD, Wilbraham, Mass
- Marc Zins, MD, Paris, France
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FOOTNOTES
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Part 1 of this case appears 4 months previously and may contain larger images.
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REFERENCES
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Balthazar EJ. CT of gastrointestinal tract: principles and interpretation. AJR Am J Roentgenol 1991; 156:23-32.[Abstract/Free Full Text]
-
Gayer G, Apter S, Hofmann C, et al. Intussusception in adults: CT diagnosis. Clin Radiol 1998; 53:53-57.[Medline]
-
Merine D, Fishman EK, Jones B, et al. Enteroenteric intussusception: CT findings in nine patients. AJR Am J Roentgenol 1987; 148:1129-1132.[Abstract/Free Full Text]
-
Bar-Ziv J, Solomon A. CT in adult intussusception. Gastrointest Radiol 1991; 16:664-666.
-
Urbano J, Serantes A, Hernandez L, Turegano F. Lipoma-induced jejunojejunal intussusception: US and CT diagnosis. Abdom Imaging 1996; 21:522-524.[Medline]
-
Eustace S, Murray SG, O’Conell D. Sonographic diagnosis of colonic lipoma-induced intussusception. J Clin Ultrasound 1993; 21:472-474.[Medline]
-
Mindelzun RE, McCort JJ. Acute abdomen. In: Margulis AR, Burhenne HJ, eds. Alimentary tract radiology. 4th ed. St Louis, Mo: Mosby, 1989; 341-343.
-
Ott D, Chen M. Specific acute colonic disorders. In: Balthazar EJ, eds. Radiology clinics of North America. Vol 32. Philadelphia, Pa: Saunders, 1994; 874.
-
Swischuk LE. Alimentary tract. In: Mitchell CW, eds. Imaging of the newborn, infant, and young child. 4th ed. Baltimore, Md: Williams & Wilkins, 1997; 430-438.
-
Yoshimitsu K, Fukuya T, Onitsuka H, et al. Computed tomography of ileocolic intussusception caused by a lipoma. J Comput Assist Tomogr 1989; 13:704-706.[Medline]
-
Olmsted WW, Ros PR, Hjermstad BM, et al. Tumors of the small intestine with little or no malignant predisposition: a review of the literature and report of 56 cases. Gastrointest Radiol 1987; 12:231-239.[Medline]
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