Obstructive duodenal lipoma successfully treated by endoscopic polypectomy

Obstructive duodenal lipoma successfully treated by endoscopic polypectomy Duodenal lipoma is a rare finding at exploratory laparotomy. In one retrospective surgical series, lipoma comprised 2.8% of 178 benign tumors resected from the stomach, the duodenum, and the small bowel.1 Clinical manifestations of duodenal lipoma include ulceration, hemorrhage, intussusception, and obstruction of the intestinal lumen. A case of duodenoduodenal intussusception caused by lipoma of the duodenum is presented. Case report. A 69-year-old woman was hospitalized with a 2-week history of nausea, vomiting, and abdominal pain. The patient could not tolerate ingestion of any food and had lost 5 kg of weight since the onset of symptoms. The medical history included only hypertension and obesity. At upper endoscopy, there was total obstruction of the second portion of the duodenum. CT revealed a large intramural mass continuous with the second and third portions and findings consistent with duodenoduodenal intussusception (Fig. 1). Contrast radiography demonstrated the mass in the duodenum but no evidence of intussusception (Fig. 2). A second EGD identified a large, lobulated, polypoid lesion in the second portion of the duodenum, with a wide base and a large, pedunculated head as the cause of the intussusception (Fig. 3). The lesion was removed by endoscopic electrosurgical snare polypectomy, and the specimen recovered. The final histopathologic diagnosis was lipoma (5 3 3 3 1.5 cm). The last endoscopy showed implantation of the base of the lipoma. The patient was well at 12 months’ follow-up. Discussion. Lipoma is the second most common benign tumor of the GI tract. Of those arising within the small bowel, the ileum is the most common site. There is no report of malignant transformation of a GI lipoma.2 The occurrence of symptoms relates to the size of the lesion: 75% of those greater than 4 cm in diameter produce symptoms, which include those of intussusception, intestinal obstruction, and/or hemorrhage. Intussusception of the duodenum caused by lipoma is rare, there being only 5 cases reported in English-language publications.3-7 The first was reported by Knight and Blake3 in 1951. The case of a 12-year-old patient with acute pancreatitis reported by McGrath et al.7 is highly unusual. The roentgenographic diagnosis of duodenal intussusception includes the presence of an intraluminal mass lesion with intussusception of the second, third, and fourth

Figure 1. CT image showing large intraluminal lipoma in second portion of duodenum. Arrows indicate mass intussuscepted to the distal portion of the duodenum. The low attenuation value of the mass is synonymous with fat.

Figure 2. Barium contrast radiograph at 20 minutes after ingestion of barium showing incomplete obstruction of proximal second part of duodenum.

Reprint requests: Jean-Louis Caillot MD, PhD, Department of Emergency Surgery, University Hospitals of Lyons, Centre Hospitalier Lyon-Sud, F-69495, Pierre-Be´nite, France. Copyright Ó 2003 by the American Society for Gastrointestinal Endoscopy 0016-5107/2003/$30.00 + 0 PII: S0016-5107(03)02232-6 938

GASTROINTESTINAL ENDOSCOPY

Figure 3. Endoscopic view of lipoma. VOLUME 58, NO. 6, 2003

Letters to the Editor

portions of the duodenum. In the present case, the intussusception and the lesion were noted on CT; because of the fat content, negative absorption coefficients are typical of lipoma. Contrast radiography of the upper GI tract demonstrated a partial obstructive stenosis in the proximal second portion of the duodenum. The typical endoscopic appearance is that of a smooth, hemispherical polypoid lesion with a wide base. The treatment of patients with symptoms from duodenal lipoma usually is surgery. All 5 reported patients with intussusception secondary to a duodenal lipoma were treated surgically. In 4 cases, the surgery consisted of a reduction after duodenotomy and polypectomy, whereas, in one case, a segmental resection of the involved portion of the jejunum was performed. To our knowledge, the present case is the first reported of a duodenal intussusception from a lipoma treated endoscopically. The pedunculated lesion was accessible endoscopically and was removed by standard electrosurgical snare polypectomy.8,9 Marie-Ce´cile Blanchet MD Eric Arnal MD Philippe Paparel MD Franc¸ois Grima MD Eric J. Voiglio MD, PhD Jean-Louis Caillot MD, PhD Service d’Urgences Chirurgicales Centre Hospitalier Lyon-Sud Pierre-Be´nite, France

REFERENCES 1. Mendes da Costa P, Beernaerts A. Benign tumours of the upper gastro-intestinal tract (stomach, duodenum, small bowel): a review of 178 surgical cases. Belgian multicentric study. Acta Chir Belg 1993;93:39-42. 2. O’Riordan B, Vilor M, Herrera L. Small bowel tumors: an overview. Dig Dis 1996;14:245-57. 3. Knight CD, Black BM. Duodenal intussusception due to lipoma. Mayo Clin Proc 1951;26:320-3. 4. Stayman JW, Heath AO. Intussusception from duodenal lipoma. Penn Med 1966;69:43-5. 5. Weiss A, Mollura JL, Profy A, Cohen R. Two cases of complicated intestinal lipoma. Review of small intestinal lipomas. Am J Gastroenterol 1979;72:83-8. 6. Jennings BS, Doerr RJ. Duodenal lipoma causing intussusception. Surgery 1989;105:560-3. 7. McGrath FP, Moote DJ, Langer JC, Orr W, Somers S. Duodenojejunal intussusception secondary to a duodenal lipoma presenting in a young boy. Pediatr Radiol 1991;21: 590-1. 8. Tung CF, Chow WK, Peng YC, Chen GH, Yang DY, Kwan PC. Bleeding duodenal lipoma successfully treated with endoscopic polypectomy. Gastrointest Endosc 2000;54: 116-7. 9. Imamura K, Fuchigami T, Iida M, Ohgushi H, Omae T, Kimura Y, Iwashita A. Duodenal lipoma: a report of three cases. Gastrointest Endosc 1983;29:223-4. VOLUME 58, NO. 6, 2003

LETTERS TO THE EDITOR Colonic explosion complicating colonoscopic electrotherapy To the Editor: The report by Ben Soussan et al.1 of argon plasma coagulation (APC) treatment of radiation proctopathy complicated by colonic explosion is an important contribution. I believe, however, significant information may be missing. Both of the reported colonic explosions complicating colonoscopic electrosurgery occurred after bowel preparation with a fermentable agent.2,3 Soussan et al.1 prepared their patient with Normacol enemas (Norgine Pharma, Paris, France). This product is unavailable in the United States. It would be useful to know if it contains a fermentable ingredient. Michael J. Henry, MD Gundersen Lutheran Clinic La Crosse, Wisconsin

REFERENCES 1. Soussan EB, Mathieu N, Roque I, Antonietti M. Bowel explosion with colonic perforation during argon plasma coagulation for hemorrhagic radiation-induced proctitis. Gastrointest Endosc 2003;57:412-3. 2. Bigard MA, Gaucher P, LaSalle C. Fatal colonic explosion during colonoscopic polypectomy. Gastroenterology 1979;77: 1307-10. 3. Raillat A, De Saint-Julien J, Abgrall J. Colonoscopic explosion during endoscopic electrosurgery after bowel preparation with mannitol. Gastroenterol Clin Biol 1982;6:301-2. PII: S0016-5107(03)02333-2

Response: I appreciate the remarks of Dr. Henry concerning the supposed role of Normacol enemas in the genesis of the colonic explosion during APC. I agree that fermentable agents increase the risk of bowel explosion during APC. However, the two active ingredients in the Normacol enema (monosodium phosphate and disodium phosphate) are not fermentable agents, so that the use of this enema does not explain the colonic explosion. I believe that the quality of bowel preparation in our patient appears to have been the initiating factor in this complication. Thus, we now perform rectal or colonic APC only in patients with well-prepared colons in which there is no residual stool. Emmanuel Ben Soussan, MD Department of Gastroenterology Rouen University Hospital Ch. Nicolle Rouen Cedex, France PII: S0016-5107(03)02334-4 GASTROINTESTINAL ENDOSCOPY

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