EP610 - A case of colonic lipoma causing intussusception in a 67-year-old man

Author(s)

• AY

  Angela Yang, B.S.

  Medical Student
  Sidney Kimmel Medical College
  Philadelphia, Pennsylvania, United States

  Disclosure information not submitted.

ePoster Presenter(s)

• 

  Deirbhile A. Martin, MD (she/her/hers)

  Resident Doctor
  Thomas Jefferson University Hospital
  Thomas Jefferson University Hospital
  Philadelphia, PA, United States

  Disclosure information not submitted.

Author(s)

• 

  Allison Doermann, MD (she/her/hers)

  Physician Resident
  Thomas Jefferson University Hospital
  Philadelphia, PA, United States

  Disclosure information not submitted.
• AK

  Aleksandra Karaseva, MD

  Physician Resident (Pathology)
  Thomas Jefferson University Hospital
  Philadelphia, Pennsylvania, United States

  Disclosure information not submitted.
• BZ

  Brian Zilberman, MD

  Colon & Rectal Surgeon
  Cooper University Hospital
  Cherry Hill, New Jersey, United States

  Disclosure information not submitted.
• JP

  Juan Palazzo, MD

  Pathologist
  Thomas Jefferson University Hospital
  Philadelphia, Pennsylvania, United States

  Disclosure information not submitted.
• JM

  Jennifer L. Miller-Ocuin, MD, FACS

  Associate Professor of Surgery
  Thomas Jefferson University
  Philadelphia, Pennsylvania, United States

  Disclosure information not submitted.
• BP

  Benjamin Phillips, MD, FACS, FACRS

  Chief, Division of Colorectal Surgery
  Thomas Jefferson University Hospital
  Philadelphia, Pennsylvania, United States

  Disclosure information not submitted.
• GI

  Gerald Isenberg, MD

  Professor of Surgery
  Sidney Kimmel Medical College
  Philadelphia, Pennsylvania, United States

  Disclosure information not submitted.
• AM

  Andrew Morgan, MD

  Assistant Professor
  Jefferson University Hospital
  Philadelphia, Pennsylvania, United States

  Disclosure information not submitted.

Purpose/Background: Colonic intussusception is exceptionally rare in adults and can result in mechanical large bowel obstructions. Most commonly, intussusception is caused by a lead point lesion, typically malignancy (60-65% of cases), but in some cases can be caused by benign disease such as lipomas. Here, we present an unusual case of a 67-year-old man with a history of suspected sigmoid lipoma on prior imaging who presented with abdominal pain and bright red blood per rectum, and was found to have intussusception.

Methods/Interventions: A CT scan was obtained showing long segment colo-colonic intussusception from the mid-descending colon to the rectum with lead point at a 9.2 cm fat-containing lesion in the sigmoid colon. This mass had also previously been described on routine screening colonoscopy, which showed a sub-mucosal non-bleeding 5 cm mass of benign appearance. The patient underwent surgical intervention with diagnostic laparoscopy, which showed an obvious intussusception of the distal descending colon into the sigmoid colon with viable appearing bowel on either ends of this lesion. Given the size of the lesion as well as dense lateral and retroperitoneal adhesions, the procedure was converted to an open lower midline laparotomy. A sigmoidectomy was performed with an end-to-side colorectal anastomosis, and flexible endoscopy showed healthy-appearing mucosa with negative air leak on insufflation test.

Results/Outcomes: The post-operative course was largely uncomplicated. The patient had return of spontaneous bowel function on post-operative day 3 and was discharged home on post-operative day 6. He was found to have an intra-abdominal hematoma that was treated with percutaneous drainage. During his in-office follow up visit on post-operative day 54, the patient was doing well with no complaints and planned to obtain interval colonoscopy in 6 months.

Conclusion/Discussion: Lipomas of the colon are uncommon, with an estimated incidence of 0.2 - 4.4 %. Lipomas greater than 4 cm are defined as giant lipomas and are more likely to be symptomatic. The present case describes a giant sigmoid lipoma measuring 9 cm, making it one of the larger lesions reported in this location. Unlike the typical discovery of lipomas at the time of acute intussusception, this patient had a known history based on serial imaging and endoscopy, showing progressive enlargement of the lipoma from 5 to 9 cm. This provides valuable insight into the natural history of giant lipomas, which is rarely documented. This case raises important questions such as: should a size threshold be considered for giant colonic lipomas to be prophylactically removed? Also, is there value in surveillance imaging or more frequent colonoscopy screenings? Our patient remained asymptomatic and was followed for years without intervention, but eventually did progress to need an urgent surgical intervention. With advancements in cross-sectional imaging and endoscopy, the incidence of colonic lipomas is increasing and raises questions regarding timing of intervention for these lesions.

Sigmoid Colonic Lipoma Gross and Histo-Pathology
Figure 1. Opened sigmoid colon specimen demonstrating a pedunculated intraluminal polyp measuring 7.5 × 6 × 2.5 cm. The polyp surface is smooth with patchy hemorrhagic discoloration. The stalk is attached to the adjacent mucosal surface. Figure 2. Cut surface of the polyp demonstrating a well-circumscribed, lobulated, homogeneously yellow lesion with a soft, greasy consistency, surrounded by a thin, delicate capsule. Figure 3. Low-power view (H&E, 4×) showing a well-circumscribed lesion composed of lobules of mature adipocytes separated by paucicellular fibrous septa. Figure 4. High-power view (H&E, 20×) demonstrating mature adipocytes without cytologic atypia, lipoblasts, or necrosis.