Adult intussusception is a rare clinical condition account only about [1-5] % of intestinal obstruction. Moreover, presence of prolapsed colonic intussusception is another extremely rare clinical finding compered to small bowel to small bowel and small bowel to colonic intussusception. Intussusception in adult is generally not benign clinical condition as of pediatrics. Usu ally associated with pathologic lead point in more than 90% and those pathologic lead points are malignant condition in more than 60% of cases. The leading point protrude into distal lumen of adjacent bowel and pull proximal adjacent bowel segment through anterograde peristalsis. Subsequently telescopes into distal adjacent lumen along with its mesentery, which may later compromise the blood flow and simultaneously cause luminal obstruction.

Adult intussusception has no peculiar clinical presentation. Often patient present with longstanding abdominal cramp un t il it results in complete bowel obstruction. However, in case of prolapsed intussusception patient may seek medical atten t ion early due to obvious discomfort from associated pain and defecation difficulty. Diagnosis of adult intussusception require thorough clinical evaluation and optimum investigation with; Ultrasound, colonoscopy, CT-scan or MRI is crucial due to its pathologic condition. But, if patient present with complete ob struction and gangrenous bowel surgical exploration and post op diagnosis is inevitable.

Overall, gaol of surgical management is enblock resection of intussusception mass and restoration of bowel continuity in an emergency case. However, proper oncologic resection is required if preoperative accurate diagnosis is obtained. The options surgical approach may be based on the case scenario, perineal resection is inevitable for oedematous prolapsed gan grenous irreducible intussusception to prevent further perfora tion and iatrogenic anal sphincter injury

History and physical examination: This is a 65-year- old fe male patient presented with a compliant of protrusion of mass per anus of five days, it was painful and it didn’t reduce sponta neously, she had history of bloody diarrhoea one week prior to the protrusion of the mass. She didn’t passed stool over the last three days. For this suffering she went to the nearby local hospi tal and reduction tried but unsuccessful. Otherwise, she had no, she passes flatus, no distension, no vomiting, no chronic cough, no difficulty of urination, no trauma/ surgical history, no weight loss, no smoking history, no previous bowel habit change. On objective evaluation: the patient was acute sick looking in pain, vital signs were BP-130/85mmHg. PR-88, RR-26, T-36.6°c, per t inent findings was on abdominal examination; DRE- there was prolapsed intususceptum bowel segment with gangrenous mu cosa circumferentially at distal end of prolapsed mass but rec tal wall was pinkish and there was also a polypoid darken firm palpable mass in the lumen of prolapsed intususceptum. The examining finger able to pass between protruded mass and rec tal wall and irreducible (Figure 1).

Investigations

On labs exam; on complete blood count profile WBC 13.93×103, HCT-39.9% Serum electrolyte results; K+-(3.7mEq/L), Na+-(140mEq/L), Liver enzymes; GPT;33U/L, GOT-51.8U/L, ALP 58.2U/L, Serum Creatinine-0.53g/L.

Management outcomes and follow ups

With all the above clinical evidences adult-onset gangre nous prolapsed coloanal intussusception was diagnosed. After patient was optimized for exploration and she was taken to operation theatre, prepared and approached both abdominal and perineal. Intraoperative finding was that a part of sigmoid colon telescoped into rectum and prolapsed through the anal opening and a prolapsed intususceptum mass was frankly gan grenous (Figure 1). A gangrenous prolapsed mass was resected perineally and viable segment reduced to abdomen (Figure 2 & 3). The remain part of intususceptum which involves sigmoid colon resected enblock and colo-colic anastomosis was done through the abdominal approach (Figure 4). A resected mass was examined and there was polypoid soft to firm intraluminal mass arising from mid sigmoid colon and sample sent for histo pathologic study Figure 4). Later the biopsy results confirmed sigmoid colon luminal lipoma (Figure 5 & 6). Post operatively patient was improved discharged home. On Subsequent follow ups the patient is doing well.

Prolapsed sigmoido-rectal intussusception in adult with pathologic lead point of colonic lipoma is a rare clinical condi tion in literature. From data of 203 literature review the over overall incidence adult intussusception was 2-3/100,000 pre dominantly affects female with median age of 51.57 years. However, the exact incidence of prolapsed sigmoido-rectal in tussusception is not yet known [1-4].

Intussusception in adult is generally not benign clinical con dition as of pediatrics. Usually associated with pathologic lead point in more than 90% and those pathologic lead points are malignant condition in more than 60% of cases. The leading point protrude into distal lumen of adjacent bowel and pull proximal adjacent bowel segment through anterograde peri stalsis. Further telescoping of proximal bowel segment into distal along with its mesentery in single segment or compound segment of intususceptum lead to vascular flow compromise and luminal mechanical obstruction. The commonest adult in tussusception is small bowel to small bowel and small bowel to colonic intussusception and the pathologic lead points are usually, adenocarcinoma, benign polyps and colonic lipoma. However, colonic intussusception by lead point of lipoma is rare f inding, sigmoid colon is second common site of colonic lipoma causing intussusception next to transverse colon. Majorities (90%) of colonic Lipomas originate from submucosa and sessile type and rarely pedunculated with average size of (5.9×4.5×3.4) cm and the largest (16×11×11) cm located at ascending colon is documented in literature. In addition, the presence of prolapse in sigmoido-rectal intussusception with pathologic lead point of colonic lipoma will further potentiate additional complications from progress of septic condition and bowel perforation due to bowel exposure to external mechanical shear apart from blood flow compromise and acute bowel obstruction [5-7].

Here we are reporting a 65-year-old female patient present ed with prolapsed sigmoido-rectal intussusception with patho logic lead point of a pedunculated mid sigmoid submucosal originated lipoma which is very rare clinical condition.

Generally, adult intussusception presents with history of longstanding abdominal cramp in more than 83.17%, intermit tent bleeding per rectum and constipation, vomiting and mild abdominal distension, until complete bowel obstruction results in which they may exhibit cardinal signs of mechanical bowel obstruction. On the other hand, prolapsed intussusception present early with mass protrusion per rectum with associated pain and acute obstruction [8,9].

Diagnosis of adult intussusception generally need clinical evidence and accurate interpretation of radiological imaging, intraoperative finding and biopsy result. Ultrasound can assess vascularity status, presence of target sign, intrabdominal asso ciated mass but it’s always operator dependent. CT-scan and MRI provide more informative image evidences for diagnosis and management plan as well. Colonoscopy is also important to know intraluminal pathologic conditions and histopatho logic study before further treatment plan. However, in clinical scenario of acute bowel obstruction with a progressive septic condition, the preoperative diagnosis may be challenging and retrospective diagnosis after exploration and optimum treat ment [10-12].

The mainstay of treatment in adult intussusceptions is en block surgical resection in case of acute bowel obstruction and in the presence of progressive of septic condition, particularly gangrenous prolapsed sigmoido-rectal intussusception. The choice of surgical approach may depend on clinical scenario and pathologic site. For perineal with abdominal approach or open vs laparoscopic/endoscopic technique. The most commonly performed procedure for colonic lipoma induced intussuscep t ion was right hemicolectomy (32.21%) and Sigmoidectomy was only 19.14% Overall gaol of surgical intervention includes; relief of acute bowel obstruction, control of septic focus from gangre nous bowel, prevention peritoneal seeding from perforation of malignant intussusception and restoration of bowel continuity by anastomosis or diversion colostomy or ileostomy based of clinical condition of patients [13-18].

Protrusion of a mass per anus in adults warrants consider ation of sigmoido-rectal intussusception as a differential diag nosis. In cases of gangrenous, irreducible prolapsed intussus ception, a combined abdominal and perineal surgical approach is essential for relieving bowel obstruction, controlling sepsis, and preventing complications like malignant perforation and peritoneal seeding, while ensuring accurate diagnosis and de finitive treatment.

Author contribution

All authors had involved in the process of edition and ap proved the final manuscript document.

Belay Mellese Abebe: Conceptualization, supervision, data curation, validation; Murtii Teressa Obolu: writing original draft, review editing, data curation, Software; Gediyon Ge tachew Gebo: Data curation & Methodology; Biruk Woisha Bo gale: Data curation & Methodology; Teketal Tadesse Geremew: Data curation & Methodology; Alemwosen Teklehaimanot: Data curation & Methodology.

Informed consent

Formal written informed consent is taken from parents for publications along with accompanying images, any identifica tion part has been anonymised for the privacy and confidential ity of patients and it will be available up on request by journal chief editor.

Conflict of interest

No conflict of interest in computation.

Acknowledgements

We would like to express our gratitude to the patients’ par ents for providing informed consents for publication along with accompanying image and everyone else who helped with the intraoperative photo and the radiologic image collection.