|Year : 2023 | Volume
| Issue : 6 | Page : 517-519
Unusual presentation of ileal intussusception due to submucosal lipoma in a child and its management
Nisha Girish, Naveen Thomas, Gayathri Natraj, KV Satish Kumar, Neena John
Department of Pathology, Bangalore Baptist Hospital, Bengaluru, Karnataka, India
|Date of Submission||12-Mar-2023|
|Date of Decision||12-Jun-2023|
|Date of Acceptance||23-Jun-2023|
|Date of Web Publication||02-Nov-2023|
Department of General Surgery, Bangalore Baptist Hospital, Vinayaka Nagar, Hebbal, Bengaluru - 560 024, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Idiopathic intussusception is the most common form of intussusception in infants and young children. In older children and adults, intussusception being rare, the lead point is usually an underlying bowel pathology (Meckel's diverticulum, hemangioma, carcinoids, polyps, submucous lipomas, etc.) and these are called pathological lead points (PLP's). The management of an obese child with recurrent abdominal pain for over 2 years, diagnosed with ileo-ileal intussusception due to submucosal lipoma is reported here.
Keywords: Intussusception, recurrent, submucosal lipoma
|How to cite this article:|
Girish N, Thomas N, Natraj G, Satish Kumar K V, John N. Unusual presentation of ileal intussusception due to submucosal lipoma in a child and its management. J Indian Assoc Pediatr Surg 2023;28:517-9
|How to cite this URL:|
Girish N, Thomas N, Natraj G, Satish Kumar K V, John N. Unusual presentation of ileal intussusception due to submucosal lipoma in a child and its management. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Dec 9];28:517-9. Available from: https://www.jiaps.com/text.asp?2023/28/6/517/389328
| Introduction|| |
Idiopathic intussusception is the most common form of intussusception in infants and young children. The lead point which incites the intussusception in younger children is enlarged Peyer's patches. In older children and adults, intussusception being rare, the lead point is usually an underlying bowel pathology (Meckel's diverticulum, hemangioma, carcinoids, polyps, and submucosal lipomas) and these are called pathological lead points (PLPs). The management of an obese child with recurrent abdominal pain for over 2 years, diagnosed with ileoileal intussusception due to submucosal lipoma is reported here.
| Case Report|| |
A 10-year-old obese child (weighing – 70 kg) was on psychiatric treatment for suspected psychosomatic disorder for over 3 years. He had multiple prior admissions for recurrent abdominal pain and investigations failed to reveal any surgical pathology. In the current admission, he presented with severe colicky abdominal pain for 5 days. Clinically, the abdomen was mildly distended with diffuse tenderness, more in the right iliac fossa. His blood picture and serum chemistry were all essentially normal. An abdominal X-ray was nonspecific and ultrasound showed mesenteric lymphadenopathy. A contrast-enhanced computed tomography (CECT) abdomen [Figure 1] showed an ileoileal intussusception with enlarged mesenteric node. The child was managed conservatively, but his pain was persistent. He was electively posted for diagnostic laparoscopy. A standard three-port laparoscopy showed the presence of dilated proximal ileum with interloop fibrous adhesions and a large lymph node in the adjacent mesentery. An attempt at release of adhesions failed to show the anatomy clearly and the segment was eviscerated through extended umbilical port. There was a sac-like dilatation of 15 cm of ileum with a diameter of 8 cm with a large submucosal lump (3 cm) at the distal end [Figure 2]. A limited resection of the involved segment was done with primary bowel anastomosis and the ports were sutured. Postoperatively, the child recovered well and was discharged on 6th postoperative day. The biopsy confirmed a submucosal lipoma of ileum. The child had major wound collection which was drained and healed well on follow-up. The child presented to the outpatient clinic with recurrent night pain with no other bowel symptoms. A repeat ultrasound and CECT scan failed to reveal any pathology. The child was referred to further psychological counseling and is doing well.
|Figure 1: (a) Sac-like dilated ileum with narrow distal and proximal end. (b) Cut section showing characteristic appearance of submucousal lipoma. (c) Resection and anastomosis done through the umbilical port. (d) Appearance of scar on follow-up (after clearance of a major wound infection)|
Click here to view
|Figure 2: 10x Submucosal adipocytic lesion composed of tubules of mature adipose tissue with thin septae and congested thin-walled blood vessels|
Click here to view
| Discussion|| |
Over 90% of intussusceptions in children are primary (idiopathic). The intussusceptions are usually due to enlarged Peyer's patches and occur in the ileocecal segment. In 4%–14% of cases, a PLP may be found and this increases with increasing age of the child (over 3 years). Meckel's diverticulum (inverted) is the most common lead point in 20%–50% of intussusceptions associated with PLPs. Lipomas of the gastrointestinal tract (GIT) are the second most common benign lesions seen in colon (65%–75%), small intestine (20%–25%), stomach, and esophagus with a peak incidence in sixth or seventh decade. Most GIT lipomas are asymptomatic and <50% of adult patients who have intestinal lipomas become symptomatic (intussusception, obstruction, or hemorrhage). Intestinal lipomas, although rare, have been previously reported to cause intussusception in children. There are three pathological types of intestinal lipomas: (i) intermuscular type; (ii) subserosal type; and (iii) submucosal type. The tumors arise from the submucosa in 90% of cases, while the remainders are usually subserosal. In a systematic review of 147 cases of small bowel lipoma over 20 years, there were 138 adults and only 9 children with small bowel lipomas. For pediatric age group, small intestinal lipomas, median age at diagnosis is 8 years with a range from 4 to 14 years and highly echoic masses on ultrasound or appear as round or oval, well-defined, hypointense, and intraluminal masses on computed tomography scans. The treatment of lipomas depends on their symptoms. Surgical resection is usually the treatment of choice for symptomatic gastrointestinal lipomas. Partial small bowel resection can either be done by laparotomy or laparoscopy. For solitary lesions, resection is usually definitive. Malignant transformation and recurrence of lipomas have not been reported.
The surgical diagnosis was a challenge in our index patient as he was obese, with a background illness of psychosomatic disorder. Laparoscopy was advantageous as the enlarged segment of bowel could be eviscerated through the widened umbilical port avoiding a major laparotomy and resection and anastomosis could be performed easily extracorporeally.
| Conclusion|| |
PLPs are expected in older children presenting with intussusception and in those who present with persisting small bowel intussusceptions. Submucosal lipomas of the small bowel are rare in children and most are asymptomatic. A preoperative diagnosis requires a high level of clinical suspicion and limited resection of the involved segment is curative. As in our index case, a laparoscopic-assisted resection was successful.
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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Daneman A, Navarro O. Intussusception. Part 2: An update on the evolution of management. Pediatr Radiol 2004;34:97-108.
Ghritlaharey R. Secondary intussusception in infants and children. Ann Natl Acad Med Sci 2021;57:53-7.
Manouras A, Lagoudianakis EE, Dardamanis D, Tsekouras DK, Markogiannakis H, Genetzakis M, et al.
Lipoma induced jejunojejunal intussusception. World J Gastroenterol 2007;13:3641-4.
Cheikhrouhou T, Dhaw MB, Zouari M, Zitouni H, Kallel R, Naourez Gouiaa, et al
. Small intestinal submucosal lipoma: A rare cause of secondary intussusception in a child. Ann Pediatr Surg 2021;17:47.
Farkas N, Wong J, Bethel J, Monib S, Frampton A, Thomson S. A systematic review of symptomatic small bowel lipomas of the jejunum and ileum. Ann Med Surg (Lond) 2020;58:52-67.
Asaumi Y, Miyanaga T, Ishiyama Y, Hattori M, Hashizume Y. Pediatric ileoileal intussusception with a lipoma lead point: A case report. Gastroenterol Rep (Oxf) 2014;2:70-2.
[Figure 1], [Figure 2]