Small intestinal lipomas: Diagnostic value of multi-slice CT enterography

A rare presentation of retroperitoneal liposarcoma presented with jejunal intussusception: An interesting radiological findings

A jejunal intussusception as a presentation of retroperitoneal liposarcoma (RLPS) is a rare occurrence. The majority of RLPS are presented as an abdominal mass, however, having a jejunal obstruction is an interesting case. The aim is to describe the management of jejunal intussusception secondary to atypical lipomatous tumours with concurrent RLPS. A 61-year-old lady presented with a sudden onset of intestinal obstruction with 1 month of constitutional symptoms and an enlarging right lumbar mass. Computed tomography showed a small bowel intussusception with diffuse peritoneal and retroperitoneal lipomatosis. Emergency exploratory laparotomy, segmental bowel resection, and partial excision of intraperitoneal mesenteric lipoma were performed. A stage En-bloc resection of the RLPS and right nephrectomy was done later. However, she refused for subsequent surgery. A complete resection is the gold standard in managing RLPS. In this report, the management is rendered not to the standard as the patient first presented with intestinal obstruction requiring emergency reduction with a piecemeal resection. A stage surgery was required to determine a promising prognosis, but the patient refused such surgery. A small bowel intussusception in adults is rare but is mostly caused by a tumor or neoplasm. Early recognition of the complexity of the case should be preempted and referred to the tertiary team for further definitive surgery. Patient exhaustion from the subsequent surgery might hamper the only management available for the case.

Laparoscopic management of an ileal lipoma presenting with massive gastrointestinal haemorrhage

ABSTRACT

Small bowel lipomas are benign submucosal neoplasm composed mainly of mature adipose tissue. Despite their rare occurrence, lipomas are the second most common benign tumour of the small intestine. These tumours are mostly small in size and remain clinically asymptomatic. However, larger lesions tend to be more symptomatic, presenting with complications such as intussusception, bleeding or obstruction. Definitive surgical or endoscopic intervention is indicated in such symptomatic lipomas. Herein, we describe a rare case of ileal lipoma presenting with ileo-ileal intussusception and a life-threatening haemorrhage that was managed by laparoscopic-assisted ileal resection.

A case report of small intestinal volvulus caused by lipomatosis of the small intestine successfully treated with enterectomy

Small intestinal lipomatosis is a rare condition that presents a diagnostic challenge due to the absence of identifiable clinical symptoms and limitations of small intestine examination methods. Consequently, preoperative diagnosis is difficult and only a limited number of cases have been documented in the scientific literature. Here, we report a rare case of volvulus caused by small intestinal lipomatosis. A 58-year-old female patient was tentatively diagnosed with acute ileus. The whirl sign was detected using abdominal three-dimensional enhanced computed tomography, along with marked local intestinal dilation and multiple irregular fat-like containing lesions. During surgery, abnormal dilation of the small intestine between 80 and 220 cm from the ileocecal valve was detected and the affected intestine displayed a folded and twisted configuration. Examination of the resected intestine showed that the inner wall of the diseased intestinal lumen was covered with more than 100 lipomas of different sizes, the largest of which measured ~8.0 cm in diameter. Based on clinical symptoms alone, it was difficult to identify the cause of intestinal volvulus before surgery. Complete resection of the affected small intestine and subsequent pathological analysis yielded a definitive diagnosis of small intestinal lipomatosis. While small intestinal lipomatosis is a rare condition, prognosis is favorable if diagnosed early and treated appropriately. The application of three-dimensional enhanced computed tomography imaging can aid in accurate diagnosis, while complete resection of the affected small intestine is crucial to improve patient prognosis.

Role of clinical and multidetector computed tomography (MDCT) features in the prediction of patients with intestinal lipoma developing intussusception

Background

Intestinal lipoma is considered the most common benign tumor that causes intussusception. This retrospective case-control study aimed to present the clinical and multidetector computed tomography (MDCT) features between intestinal lipomas with and without intussusception and examine risk factors that predict intussusception caused by intestinal lipomas.

Methods

We retrospectively analyzed 281 adult patients diagnosed with intestinal lipoma by radiologists using whole-abdominal MDCT between January 2015 and August 2022. Patients were divided into adult intussusception (AI) and non-AI groups based on MDCT images. Univariate logistic regression was performed to identify risk factors for intestinal lipoma-induced intussusception.

Results

A total of 281 patients with intestinal lipomas were included in the study, with an average age of 68.0±11.3 years, and the male to female ratio was about 1:1.4. Among them, 24 patients developed lipoma-induced intussusception. Patients in the AI group presented with more abdominal pain (70.8% vs. 47.1%, P=0.03), nausea/vomiting (37.5% vs. 14.8%, P=0.009), hematochezia/melena (29.2% vs. 11.3%, P=0.02), and abdominal tenderness (66.7% vs. 24.9%, P<0.001). Lipomas were more common in the small bowel (224/281, 79.7%) than the large bowel (57/281, 20.3%). Lipomas in the AI group showed more heterogeneous hypodensity (41.7% vs. 15.6%, P=0.004), longer length (median, 2.2 vs. 1.2 cm, P<0.001), and larger volume (median, 4.1 vs. 0.6 cm3, P<0.001). In the univariate logistic regression, lipoma density [odds ratio (OR) =3.875, 95% confidence interval (CI): 1.609-9.331, P=0.003] and lipoma length (OR =3.216, 95% CI: 1.977-5.231, P<0.001) were risk factors for intestinal lipoma-induced intussusception.

Conclusions

More patients in the AI group have digestive tract symptoms than those in the non-AI group. Lipoma density and length are risk factors for intussusception in patients with intestinal lipoma. In addition, the common site of intestinal lipoma may have changed from the colon to the small intestine.

Intussusception Related to Small Intestinal Lipomas: A Case Report and Review of the Literature

Introduction

Adult intussusception is a rare disease that is difficult to diagnose and treat and is even rarer when it is caused by a lipoma of the small intestine. We reported a case of a small intestine lipoma combined with intussusception, which can guide people in future clinical work.

Case Presentation

A 51-year-old female was admitted to the hospital with “abdominal pain for 1 month.” Enhanced computed tomography (CT) of the abdomen suggested a lipoma in the left lower quadrant and a proximal intussusception. After excluding surgical contraindications, laparoscopic exploration was performed on the second day of admission, which showed a small amount of ascites in the abdominal cavity, a small intestine–small intestine-type intussusception about 20 cm from the ileocecal area and about 140 cm from the ileocecal area, and a mass of about 2×4 cm that was palpable by laparoscopic intestinal forceps, which was protruded into the intestinal cavity with a soft texture and sound mobility. A 5 cm-long incision was made above the mass to dissect into the abdomen layer by layer, and the diseased intestine was dislodged outside the abdominal cavity with oval forceps. The intestine was reduced by hand and observed for half an hour after reduction, and the blood circulation and peristalsis of the intestine were observed to be still sound. The intestine was dissected at 2 cm from the upper and lower margins of the mass using linear anastomosis to operate small intestine side-to-side anastomosis. The intestine was opened concurrently and closed with a linear anastomosis, using 3-0 absorbable thread to reinforce anastomosis intermittently. The procedure went smoothly, and the patient was discharged on the 5th postoperative day.

Conclusion

A small intestinal lipoma combined with small intestinal intussusception is rare in clinical practice and needs to be diagnosed by asking history detailedly, physical examination, and relevant ancillary tests such as abdominal CT. Laparoscopic-assisted small incision surgery for adult intussusception combines the advantages of laparoscopic surgery and laparotomy, operating simply and easily.

Confluent Small Bowel Lipomatosis: A Rare Cause of Recurrent Abdominal Pain

Small intestine lipomatosis is rare but may be associated with pain, intussusception, and gastrointestinal bleeding. In this report, we examine the case of a 41-year-old man who had recurrent presentations to the emergency department with non-specific abdominal pain. Preoperative imaging suggested extensive infiltration of small intestine with macroscopic fat. At surgery, extensive and confluent small bowel lipomatosis were seen. The affected ileal segment was resected, and the patient remained symptom-free after surgery. Abdominal lipomatosis is a rare condition which can be completely treated by resection of the affected gut segment but is often unsuspected and difficult to diagnose. In this report, we describe a case with the most extensive lipomatosis on record with more than 70 cm of gut with confluent lipomatosis. Magnetic resonance Enterography (MRE) is a useful non-invasive diagnostic modality, although laparoscopy/laparotomy may be necessary for assessment of the extent of disease. Symptomatic cases should be treated with segmental small bowel resection, which is curative.

Submucosal Lipoma Causing Small Bowel Intussusception

Intussusception involves telescoping of one segment of the intestine into an adjacent segment. Although this diagnosis is common in the pediatric population, it is much less common in adults. One of the main reasons it may occur in adults is due to a mass. Intestinal masses can be malignant, such as gastrointestinal stromal tumors, lymphomas, or adenocarcinomas; or they can be benign. One benign lead point in intussusception is a lipoma. A lipoma usually presents on the trunk, neck, or forearm, but can rarely be seen in the gastrointestinal tract. When it presents in the intestine, it can be either asymptomatic or it can be symptomatic and causes abdominal pain, nausea, vomiting, and gastrointestinal bleeding. Furthermore, it may act as a lead point and causes intussusception. We present an adult patient with two rare findings: small bowel obstruction from intussusception caused by a benign intestinal lipoma as its lead point. The patient was promptly taken to the operating room, where the intussuscepted bowel was resected along with the lipoma, and the patient had an uncomplicated recovery. The pathology report confirmed the specimen to be a submucosal lipoma with mature adipose tissue without atypia. Although intussusception and intestinal lipomas are both rare in adults, it is important to be aware of them on the list of differential diagnoses in adult patients with abdominal pain. This is because it can cause a wide array of complications including, ischemia, bowel perforation, sepsis, shock, and peritonitis. The lead point in intussusception has the possibility of being malignant. Careful consideration of these diagnoses with prompt imaging and appropriate intraoperative management is vital for good patient outcomes.

Small intestinal submucosal lipoma: a rare cause of secondary intussusception in a child

Background

Intestinal lipomas are benign, non-epithelial, intestinal tumors with an exceptionally rare localization at the ileum. Lipomas in the small intestine occur mainly in elderly patients and seldom occur in childhood. They are frequently asymptomatic, possibly due to their slow growth. These tumors may act as a lead point of intussusception.

Case presentation

We report a rare case of double compounded ileo-ileal intussusception due to a submucosal intestinal lipoma in an 8-year-old female. To our knowledge, this is only the seventh pediatric case to be reported in the medical literature.

Conclusions

Small intestinal submucosal lipoma should be considered in case of intussusception in pediatric patients. Surgical resection seems sufficient in case of symptomatic intestinal lipoma with low morbidity.

Tumors of the jejunum and ileum: a pattern-based imaging approach on CT

Since a broad spectrum of tumors can occur in the small bowels, it is not easy to make a correct differential diagnosis among small bowel tumors on CT findings. Therefore, once a mass is detected on CT, the radiologist needs to analyze the mass based on presenting patterns such as location, multiplicity, morphology, and enhancement patterns. In this article, we will illustrate various kinds of small bowel tumors based on imaging patterns at CT to facilitate making a correct diagnosis.

Management of small bowel polyps: from small to big

PURPOSE OF REVIEW

Benign small bowel polyps or mass are clinically poorly distinguishable from malignant small bowel masses, and the diagnostic conditions are almost the same. The important point for clinicians is first to take advantage of the different available diagnostic tools to optimize the diagnostic algorithm of a small bowel polyp or mass. Next, according to the clinical situation, associated disease or sporadic situation, the difficulty is to adapt the treatment decision to the patient situation.

RECENT FINDINGS

The last 20 years have been marked by the development of major diagnostic tools for small bowel diseases (capsule endoscopy, cross-sectional imaging with enteroclysis and balloon-assisted enteroscopy) and by the major decrease of intra-operative enteroscopy as a diagnostic mean.

SUMMARY

On the basis of considerable development of capsule endoscopy and the improvement of cross-sectional small bowel imagining, small bowel polyps represent now a frequent clinical situation for gastroenterologists.

Incidental diagnosis of breast cancer in the pursuit of the treatment of intestinal obstruction

Intestinal lipomatosis is rare and often asymptomatic but can present with intestinal obstruction. Occasionally, metastatic breast cancer is identified in the ovary before a breast primary is discovered. We report the case of a 50-year-old woman diagnosed with synchronous intestinal obstruction due to lipomatosis, and incidental ovarian metastases from breast cancer. The patient presented with a 12-day history of nausea, diffuse abdominal pain, and constipation. An abdominal x-ray showed air-fluid levels, and computed tomography documented small bowel distention. An explorative laparotomy was performed, which revealed small bowel distention, an obstructive lesion of the ileocecal valve, three terminal ileum lesions, ascites, and heterogeneous ovaries. Right ileocolic resection and left oophorectomy were performed. The pathological diagnosis revealed lipomatous submucosal lesion of the ileocecal valve and ileum, and 17 lymph nodes, which were all negative for malignant cells. The oophorectomy revealed ovarian metastasis from breast carcinoma. Ascitic fluid was positive for malignant cells. Mammography and breast/axillary ultrasonography showed a solid nodule of the left breast, ductal carcinoma, and multiple enlarged left axillary lymph nodes, which were positive for neoplastic cells. Immunohistochemical evaluation showed hormonal receptor positivity and C-erb2 negativity. Breast magnetic resonance imaging showed a 14 mm left nodule and a positron emission tomography scan revealed ¹⁸F-FDG uptake in the left breast, left axillary lymph nodes, right ovary, and peritoneum. The tumor was staged as stage IV ductal breast carcinoma, cT1N1M1, Grade 2, Luminal B-like. The multidisciplinary oncological meeting proposed chemotherapy, and a re-staging breast MRI after chemotherapy, which showed a complete response. The patient started treatment with letrozole and remains disease-free 22 months after finishing chemotherapy.

Mass-forming lesions of the duodenum: A pictorial review

Recent advances in imaging have resulted in marked changes in the investigation of the duodenum, which still remains primarily evaluated with videoendoscopy. However, improvements in computed tomography (CT) and magnetic resonance (MR) imaging have made detection and characterization of duodenal mass-forming abnormalities easier. The goal of this pictorial review was to illustrate the most common conditions of the duodenum that present as mass-forming lesions with a specific emphasis on CT and MR imaging. MR imaging used in conjunction with duodenal distension appears as a second line imaging modality for the characterization of duodenal mass-forming lesions. CT remains the first line imaging modality for the detection and characterization of a wide range of duodenal mass-forming lesions.

Diagnostic performance of multi-slice CT angiography combined with enterography for small bowel obstruction and intestinal ischaemia

INTRODUCTION

This study was performed to evaluate the diagnostic performance of multi-slice CT angiography combined with enterography in determining the cause and location of obstruction as well as intestinal ischaemia in patients with small bowel obstruction (SBO).

METHODS

This study retrospectively summarized the image data of 57 SBO patients who received both multi-slice CT angiography and enterography examination between December 2012 and May 2013. The CT diagnoses of SBO and intestinal ischaemia were correlated with the findings at surgery or digital subtraction angiography, which were set as standard references.

RESULTS

Multi-slice CT angiography and enterography indicated that the cause of SBO in three patients was misjudged, suggesting a diagnostic accuracy of 94.7%. In one patient the level of obstruction was incorrect, demonstrating a diagnostic accuracy of 98.2%. Based on the results of the receiver operating characteristic (ROC) curve analysis, the diagnostic criterion for ischaemic SBO was at least two of the four CT signs (circumferential bowel wall thickening, reduced enhancement of the intestinal wall, mesenteric oedema and mesenteric vascular engorgement). The criterion yielded a sensitivity of 94.4%, a specificity of 92.3%, a positive predicted value of 85.0% and a negative predicted value of 97.3%, and the area under curve (AUC) was 0.92 (95% CI, 0.85-0.99).

CONCLUSION

Multi-slice CT angiography and enterography have high diagnostic value in identifying the cause and site of SBO. In addition, the suggested diagnostic criterion using CT signs is helpful for diagnosing intestinal ischaemia in SBO patients.

Congenital Pyloric Atresia with Distal Duodenal Atresia- Role of CT Scan

The mainstay of diagnosis of congenital pyloric atresia is by plain X-ray of the abdomen showing a large gas bubble with no gas distally. But very rarely it can be associated with distal duodenal atresia when the baby may present as lump abdomen. In such a situation apart from the X-ray, another radiological investigation is needed to delineate the exact nature of the lump. Since the role of ultrasonography is limited in intestinal pathologies and contrast studies are not informative in atresias, the CT scan is the ideal choice. We had managed a case of pyloric atresia with similar presentation with preoperative CT scan.

Pediatric ileoileal intussusception with a lipoma lead point: a case report

Intussusception is a common cause of mechanical bowel obstruction among children, with older children being more likely to have a pathological lead point. Intestinal neoplasms are rare and small intestinal lipomas are even less common. Herein we describe a case of a 7-year-old boy with ileoileal intussusception, with an ileal lipoma as the pathological lead point. Computed tomography was useful pre-operatively for revealing intussusception due to lipoma as the pathologic lead point.

Ileo-colonic intussusception secondary to small-bowel lipomatosis: A case report

Intestinal lipomatosis is a rare disease with an incidence at autopsy ranging from 0.04% to 4.5%. Because the lipomas are diffusely distributed in the intestine, most patients are symptom-free, and invasive intervention is not advised by most doctors. Here, we describe a case with intussusception due to small-bowel lipomatosis. Partial small bowel resection and anastomosis were performed because the intestinal wall was on the verge of perforation. This case indicates that regular follow-up is necessary and endoscopic treatment should be considered to avoid surgical procedures if the lipoma is large enough to cause intestinal obstruction.

Small bowel tumors: spectrum of findings on 64-section CT enteroclysis with pathologic correlation

Improvements in helical technology have made detection of benign and malignant small bowel tumors easier so that they are now frequently detected at an early stage. Sixty-four-section CT enteroclysis provides suggestive features that help determine the actual nature of a small bowel tumor in a large number of cases. Specific diagnosis of small bowel tumor is based on a combination of findings that are depicted owing to the use of the multiple capabilities of 64-section CT enteroclysis, allowing optimal planning prior to endoscopic or surgical resection.

Dedifferentiated subserosal liposarcoma of the jejunum: sonographic and computed tomographic findings with pathologic correlation

Dedifferentiated liposarcoma, one of five subtypes of liposarcomas, occurs as a consequence of the progression of well-differentiated liposarcoma to dedifferentiation. Liposarcoma arising from the subserosa of small bowel that can mimic the appearance of mesenteric liposarcoma or teratoma is extremely rare. Here, we report a case of dedifferentiated liposarcoma that developed in the subserosal layer of the jejunum and metastasized to the mesentery.