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Colonic lipomas
Colonic lipomas An endoscopic analysis Roy A. De Beer, DO Hiromi Shinya, MD New York, New York
Endoscopic observations in 22 cases of colon lipomas, combined with thorough radiographic examination, suggest that surgical intervention is no longer necessary to settle the issue of differential diagnosis of subtractive defects, particularly those at or near the i1eo-cecal junction. Special attention is directed to the "cushion" and "tenting" signs at endoscopy. Until recently the diagnosis of colon lipomas has been within the realm of standard barium contrast study, examination by water soluble contrast material, and surgical exploration. With the availabi Iity of fibercolonoscopy and direct visual ization of the entire colon lumen, the specific lesion in question can be identified and biopsied. This is a review of 22 patients with colon lipomas studied by standard contrast enema and fiberoptic colonoscopy at the Beth Israel Medical Center, New York. RADIOGRAPHIC AND CLINICAL FINDINGS In 1,827 colonoscopic examinations performed from July 1972 to July 1974, 22 cases (0.83%) of colon lipomas were found. Of the 22 patients with lipomas, 15 were referred with standard barium enemas from outside institutions or private physicians and 7 were referred from within our own hospital. Patients presented because of colon symptoms (see below) or because of the demonstration of polypoid lesions in the colon. RadiographicallY,4 were interpreted as colon lipomas, 7 as polyps, 4 as hypertrophic ileocecal valves, and 2 as cecal subtractive defects. In 5 patients, lipomas were seen endoscopically where no lesion had been apparent in barium enema films. There were 12 women and 10 men in the series. Their ages ranged from 49 to 80 years, averaging 66 years. In descending order of frequency, lipomas were found in the cecum (13), ascending colon (5), transverse colon (3), descending colon (1), and sigmoid colon (1). In 18 patients (81 %), the lipoma was located in the right colon. One patient had 2 lipomas, 1 in the cecum and 1 in the sigmoid colon. In size, the tumors ranged from 1 cm to 3 cm, averaging 2.3 cm. Eleven of the 22 cases had additional benign adenomatous polyps ranging from 0.3 cm to 1.8 cm. Six of the patients had
diverticulosis of the sigmoid colon, and 2 had undergone previous colon resection for benign colonic polyps. Clinical manifestations were minimal. Of the 22 patients, only 7 (29%) were symptomatic. Mild, nonspecific abdominal cramping or discomfort was observed in 5 of the 7 patients. However, 4 of these 7 patients also had diverticula in the sigmoid colon. Three patients had rectal bleeding. One was thought to have bled from an excoriated Iipoma of the sigmoid colon. Internal hemorrhoids and a benign peduncu lated polyp of the descending colon were considered to be the sources in the others. Four of the 7 had experienced mild, intermittent constipation and diarrhea within 12 months of their barium enema examinations, and 3 had noted a change in stool caliber. Only 3 of the 7 symptomatic patients had lipomas as their only colon lesion. ENDOSCOPIC APPEARANCES Characteristically, colon lipomas are described as smooth, soft, somewhat pliant masses with normal overlying mucosa. In their endoscopic identification, we have come to refer to the "cushion sign": a sinking, sponge-like impression is made by pressing the biopsy forceps into the bulk of the lesion. The mucosa can be then pulled up, tenting away from the mass (Figure 1). Twelve lipomas in our series exhibited this "cushion sign." Biopsy of the overlying mucosa, of course, does not yield a histologic diagnosis of the submucosal tumor in most cases. Therefore, the gross endoscopic impression is heavily relied upon in making the diagnosis. Other submucosal tumors such as hemangiomas, neurofibromas, hamartomas, leiomyomas, lymphomas and carcinoid present different gross appearances that have been well described.'"
From the Surgical Endoscopy Department, Beth Israel Medical Center, New York, New York. Reprint requests: Roy De Beer, DO, Beth Israel Medical Center, New York, N Y 10003.
90
GASTROINTESTINAL ENDOSCOPY
Figure 1. Endoscopic photographs illustrating the "cushion" sign (left) and the "tenting" sign (right), both useful in identifying lipomas. The so-called "prominent ileocecal valve" was recognized as a source of possible error in the differential diagnosis of lipomas. The radiographic similarity of prominent ileocecal valves, prolapsed valves, cecal filling defects, and lipomas has been studied in detail. s,. We made the endoscopic diagnosis of prominent ileocecal valve in 7 cases. On x-ray, 2 had been reported as polyps, 2 as filling defects, and 3 as hypertrophic ileocecal valves. When compared with a lipoma, a puckered, hypertrophied, ileocecal valve also appears to be soft and sponge-like to forceps pressure. However, the normal overlying mucosa does not generally tent away from a prominent ileocecal valve. In 1 case wherein we had diagnosed a lipoma in the cecum adjacent to the ileocecal valve, postmortem examination showed no gross evidence of lipoma to the pathologist. No comment was made about the ileocecal valve. A possible explanation is that the patient had a prominent ileocecal valve, more dynamic in life8 and therefore more readi Iy apparent endoscopically. Another patient, first thought by the endoscopic team to have a cecal lipoma, was reexamined by the same observers who then found the mass to more closely resemble a hypertrophic ileocecal valve. Biopsy specimens of 6 lipomas revealed normal colonic mucosa in all cases. One lipoma, in the sigmoid colon, was totally excised by colonoscopic polypectomy because of bleeding. The endoscopic impressiori of lipoma was confinned histologically. DISCUSSION lipomas of the colon and rectum are relatively rare.2-4,9,12 Weinberg and Feldman,l1 in reviewing 60,201 necropsies in collected series, found only 135 lipomas of the colon (0,2%). Haller and Roberts 7 found only11 lipomas
(0.32%) in 3,402 necropsies. Stout,lO reviewing 50 years' experience at Columbia Presbyterian Hospital, found only 42 lipomas among 292 tumors of the colon and rectum, excluding carcinoma, carcinoid, and adenoma. Our series of 1,827 colonoscopic examinations showing 22 lipomas (.83%) has yielded a correspondingly low frequency. In this series, as in others 2,3.7,10 lipomas of the colon have been found more often in women and most often in the sixth decade of life, Seventy-six percent of our patients were 60 years old or older. Generally, most lipomas are silent.>·· The variability and severity of symptoms seem unrelated to size and location. Abdominal pain or discomfort is the most frequent complaint reported by symptomatic patients although often in attendance with other lesions such as benign colon tumors or diverticulosis. Interestingly, half of our patients had polyps elsewhere in the colon. There is no current explanation for the predilection of lipomas for the right side of the colon. The etiology and pathogenesis of this condition are not understood, Radiographic diagnosis of lipoma was definitive in less than 20% of patients. Endoscopic visual ization supplemented in an important way the establishment of the benign nature of these submucosal tumors. Although pathologic diagnosis was clearly established in only 1 of the 22 cases, the characteristic endoscopic appearance of the lesion was such that relative assurance was felt in making the diagnosis. Satisfactory information on endoscopic views of all submucosal lesions is currently lacking so that periodic colonoscopic reexamination remains available to those interested in their study or if the patient should become symptomatic.
REFERENCES 1. BOCKUS HL, BERK jE, HAUBRICH WS: Benign Tumors of the Colon and Rectum, in Gastroenterology, 2nd Ed., Philadelphia, w. B. Saunders Co., 19&4, Ch. 72, p. 981 2. CASTRO EB, STEARNS MW: Lipoma of the large intestine: a review of 45 cases. Dis Colon Rectum, 15:441,1972 3. D'jAVID IF: Lipomas of the large intestine: review of the literature and report of a case. J Abdom Surg 111:131, 1961 4. JACKMAN Rj, BEAHRS OH: tntramuraltumors ofthe large bowel. In Tumors of the Large Bowel, Philadelphia, W. B. Saunders Co., 1968, Ch. 19, p. 223 5. FLEISCHNER FG, BERNSTEIN C: Roetgenanatomical studies of the normal ileocecal valve, Radiology 54:43, 1950 6. HINKEL CL: Roetgenological examination and evaluation of the ileocecal valve. Am J Roetgenol, 68:171, 1952 VOLUME 22, NO.2, 1975
7. HALLER jD, ROBERTS TW: Lipomas of the colon: a clinical pathological study of twenty cases. Surgery 55:773, 1964 8. NAGASAKA K, TAKEMOTO T: Endoscopy of the ileocecal valve. Gastroenterology 65:403, 1973 9. PAPr Jr, HAUBRICH WS: Endoscopic removal of colon lipomas. Gastrointestinal Endoscopy 20:66, 1974 10. STOUT AP: Tumors of the Colon and Rectum (Excluding Carcinoma, Carcinoid and Adenoma). Ed. by R. Terel!. In Diseases of the Colon and Anal Rectum, 2nd Edition, Philadelphia, W. B. Saunders Co., 1969, p. 305 11. WEINBERG T, FELDMAN MSR: Lipomas of the gastrointestinal tract. Am J Clin Path 25:272, 1955 12. WYCHULIS AR, JACKMAN RJ, MAYO CWo Submucous lipomas of the colon and rectum. Surg Gynecol Obstet 118:337, 1964
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Endoscopic observations in 22 cases of colon lipomas, combined with thorough radiographic examination, suggest that surgical intervention is no longer necessary to settle the issue of differential diagnosis of subtractive defects, particularly those at or near the i1eo-cecal junction. Special attention is directed to the "cushion" and "tenting" signs at endoscopy. Until recently the diagnosis of colon lipomas has been within the realm of standard barium contrast study, examination by water soluble contrast material, and surgical exploration. With the availabi Iity of fibercolonoscopy and direct visual ization of the entire colon lumen, the specific lesion in question can be identified and biopsied. This is a review of 22 patients with colon lipomas studied by standard contrast enema and fiberoptic colonoscopy at the Beth Israel Medical Center, New York. RADIOGRAPHIC AND CLINICAL FINDINGS In 1,827 colonoscopic examinations performed from July 1972 to July 1974, 22 cases (0.83%) of colon lipomas were found. Of the 22 patients with lipomas, 15 were referred with standard barium enemas from outside institutions or private physicians and 7 were referred from within our own hospital. Patients presented because of colon symptoms (see below) or because of the demonstration of polypoid lesions in the colon. RadiographicallY,4 were interpreted as colon lipomas, 7 as polyps, 4 as hypertrophic ileocecal valves, and 2 as cecal subtractive defects. In 5 patients, lipomas were seen endoscopically where no lesion had been apparent in barium enema films. There were 12 women and 10 men in the series. Their ages ranged from 49 to 80 years, averaging 66 years. In descending order of frequency, lipomas were found in the cecum (13), ascending colon (5), transverse colon (3), descending colon (1), and sigmoid colon (1). In 18 patients (81 %), the lipoma was located in the right colon. One patient had 2 lipomas, 1 in the cecum and 1 in the sigmoid colon. In size, the tumors ranged from 1 cm to 3 cm, averaging 2.3 cm. Eleven of the 22 cases had additional benign adenomatous polyps ranging from 0.3 cm to 1.8 cm. Six of the patients had
diverticulosis of the sigmoid colon, and 2 had undergone previous colon resection for benign colonic polyps. Clinical manifestations were minimal. Of the 22 patients, only 7 (29%) were symptomatic. Mild, nonspecific abdominal cramping or discomfort was observed in 5 of the 7 patients. However, 4 of these 7 patients also had diverticula in the sigmoid colon. Three patients had rectal bleeding. One was thought to have bled from an excoriated Iipoma of the sigmoid colon. Internal hemorrhoids and a benign peduncu lated polyp of the descending colon were considered to be the sources in the others. Four of the 7 had experienced mild, intermittent constipation and diarrhea within 12 months of their barium enema examinations, and 3 had noted a change in stool caliber. Only 3 of the 7 symptomatic patients had lipomas as their only colon lesion. ENDOSCOPIC APPEARANCES Characteristically, colon lipomas are described as smooth, soft, somewhat pliant masses with normal overlying mucosa. In their endoscopic identification, we have come to refer to the "cushion sign": a sinking, sponge-like impression is made by pressing the biopsy forceps into the bulk of the lesion. The mucosa can be then pulled up, tenting away from the mass (Figure 1). Twelve lipomas in our series exhibited this "cushion sign." Biopsy of the overlying mucosa, of course, does not yield a histologic diagnosis of the submucosal tumor in most cases. Therefore, the gross endoscopic impression is heavily relied upon in making the diagnosis. Other submucosal tumors such as hemangiomas, neurofibromas, hamartomas, leiomyomas, lymphomas and carcinoid present different gross appearances that have been well described.'"
From the Surgical Endoscopy Department, Beth Israel Medical Center, New York, New York. Reprint requests: Roy De Beer, DO, Beth Israel Medical Center, New York, N Y 10003.
90
GASTROINTESTINAL ENDOSCOPY
Figure 1. Endoscopic photographs illustrating the "cushion" sign (left) and the "tenting" sign (right), both useful in identifying lipomas. The so-called "prominent ileocecal valve" was recognized as a source of possible error in the differential diagnosis of lipomas. The radiographic similarity of prominent ileocecal valves, prolapsed valves, cecal filling defects, and lipomas has been studied in detail. s,. We made the endoscopic diagnosis of prominent ileocecal valve in 7 cases. On x-ray, 2 had been reported as polyps, 2 as filling defects, and 3 as hypertrophic ileocecal valves. When compared with a lipoma, a puckered, hypertrophied, ileocecal valve also appears to be soft and sponge-like to forceps pressure. However, the normal overlying mucosa does not generally tent away from a prominent ileocecal valve. In 1 case wherein we had diagnosed a lipoma in the cecum adjacent to the ileocecal valve, postmortem examination showed no gross evidence of lipoma to the pathologist. No comment was made about the ileocecal valve. A possible explanation is that the patient had a prominent ileocecal valve, more dynamic in life8 and therefore more readi Iy apparent endoscopically. Another patient, first thought by the endoscopic team to have a cecal lipoma, was reexamined by the same observers who then found the mass to more closely resemble a hypertrophic ileocecal valve. Biopsy specimens of 6 lipomas revealed normal colonic mucosa in all cases. One lipoma, in the sigmoid colon, was totally excised by colonoscopic polypectomy because of bleeding. The endoscopic impressiori of lipoma was confinned histologically. DISCUSSION lipomas of the colon and rectum are relatively rare.2-4,9,12 Weinberg and Feldman,l1 in reviewing 60,201 necropsies in collected series, found only 135 lipomas of the colon (0,2%). Haller and Roberts 7 found only11 lipomas
(0.32%) in 3,402 necropsies. Stout,lO reviewing 50 years' experience at Columbia Presbyterian Hospital, found only 42 lipomas among 292 tumors of the colon and rectum, excluding carcinoma, carcinoid, and adenoma. Our series of 1,827 colonoscopic examinations showing 22 lipomas (.83%) has yielded a correspondingly low frequency. In this series, as in others 2,3.7,10 lipomas of the colon have been found more often in women and most often in the sixth decade of life, Seventy-six percent of our patients were 60 years old or older. Generally, most lipomas are silent.>·· The variability and severity of symptoms seem unrelated to size and location. Abdominal pain or discomfort is the most frequent complaint reported by symptomatic patients although often in attendance with other lesions such as benign colon tumors or diverticulosis. Interestingly, half of our patients had polyps elsewhere in the colon. There is no current explanation for the predilection of lipomas for the right side of the colon. The etiology and pathogenesis of this condition are not understood, Radiographic diagnosis of lipoma was definitive in less than 20% of patients. Endoscopic visual ization supplemented in an important way the establishment of the benign nature of these submucosal tumors. Although pathologic diagnosis was clearly established in only 1 of the 22 cases, the characteristic endoscopic appearance of the lesion was such that relative assurance was felt in making the diagnosis. Satisfactory information on endoscopic views of all submucosal lesions is currently lacking so that periodic colonoscopic reexamination remains available to those interested in their study or if the patient should become symptomatic.
REFERENCES 1. BOCKUS HL, BERK jE, HAUBRICH WS: Benign Tumors of the Colon and Rectum, in Gastroenterology, 2nd Ed., Philadelphia, w. B. Saunders Co., 19&4, Ch. 72, p. 981 2. CASTRO EB, STEARNS MW: Lipoma of the large intestine: a review of 45 cases. Dis Colon Rectum, 15:441,1972 3. D'jAVID IF: Lipomas of the large intestine: review of the literature and report of a case. J Abdom Surg 111:131, 1961 4. JACKMAN Rj, BEAHRS OH: tntramuraltumors ofthe large bowel. In Tumors of the Large Bowel, Philadelphia, W. B. Saunders Co., 1968, Ch. 19, p. 223 5. FLEISCHNER FG, BERNSTEIN C: Roetgenanatomical studies of the normal ileocecal valve, Radiology 54:43, 1950 6. HINKEL CL: Roetgenological examination and evaluation of the ileocecal valve. Am J Roetgenol, 68:171, 1952 VOLUME 22, NO.2, 1975
7. HALLER jD, ROBERTS TW: Lipomas of the colon: a clinical pathological study of twenty cases. Surgery 55:773, 1964 8. NAGASAKA K, TAKEMOTO T: Endoscopy of the ileocecal valve. Gastroenterology 65:403, 1973 9. PAPr Jr, HAUBRICH WS: Endoscopic removal of colon lipomas. Gastrointestinal Endoscopy 20:66, 1974 10. STOUT AP: Tumors of the Colon and Rectum (Excluding Carcinoma, Carcinoid and Adenoma). Ed. by R. Terel!. In Diseases of the Colon and Anal Rectum, 2nd Edition, Philadelphia, W. B. Saunders Co., 1969, p. 305 11. WEINBERG T, FELDMAN MSR: Lipomas of the gastrointestinal tract. Am J Clin Path 25:272, 1955 12. WYCHULIS AR, JACKMAN RJ, MAYO CWo Submucous lipomas of the colon and rectum. Surg Gynecol Obstet 118:337, 1964
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