Gastrointestinal lipomas are benign lesions arising from the adipocytes within the intestinal submucosa5
with the first case reported by Bauer in 1757.6
With a reported incidence of 0.2% to 4.4%, lipomas are the third most common benign colonic neoplasm following hyperplastic and adenomatous polyps.7–9
Lipomas are found most commonly in the colon, with the highest frequency found in the ascending colon and cecum followed by the transverse colon, descending colon, sigmoid, and least often the rectum.10
Despite the propensity for colonic distribution, lipomas can occur anywhere along the alimentary tract, including the hypopharynx, stomach, small bowel, and esophagus.11,12
When confined to the colon, 90% of these lesions are localized to the submucosa; however, a few reports have suggested an origin in the subserosal plane.7,10
These tumors are more prevalent in women and are typically discovered during the fifth or sixth decade of life.13–15
Lipomas tend to be solitary, spherical, and smooth lesions. They vary in size and can be sessile or pedunculated. Cases of multiple lesions have been reported.10,16
Lipomas are generally asymptomatic and are identified most commonly as incidental findings during colonoscopy, surgery, or autopsy. In the minority of patients who do present with symptoms, the lesions tend to be >2 cm in diameter, as in the present case. Common symptoms include constipation, diarrhea, colicky abdominal pain, or lower gastrointestinal bleeding.7,17,18
Abdominal pain may be associated with intermittent intussusception, whereas gastrointestinal bleeding is secondary to ulceration of the overlying mucosa.16
In rare cases, patients can present with dramatic clinical symptomatology that requires urgent operative intervention,4
usually for intussusception or acute hemorrhage.6
Our patient presented with hematochezia likely secondary to the combination of the size, mucosal necrosis at the surface of the lipoma, and the patient's anticoagulation regimen.
A variety of imaging modalities are available to assist in the preoperative diagnosis of gastrointestinal lipoma. Barium enema shows colonic lipomas as ovoid, well-delineated, and smooth radiolucent masses.10
A “squeeze sign” can also be noted, which indicates a change in size and shape of the lesion due to peristalsis.19
Unfortunately, barium enema does not yield a definitive diagnosis. Computed tomography scanning is a second modality that provides a more definitive diagnosis in uncomplicated cases, where lipomas appear as sharply demarcated ovoid lesions with absorption densities of -40 to -120 Hounsfield units.20,21
In the present case, CT demonstrated a cecal mass and provided a likely diagnosis. Lastly, endoscopy is a third diagnostic tool with 2 typical findings: “Tenting” is described when the mucosa overlying the lipoma is easily retracted away from the mass with biopsy forceps, and a “cushion sign” is present when the forceps produces a soft, cushioning indentation when applied to the lipoma.22
Due to the submucosal location of these lipomas, superficial colonoscopic biopsies are often nondiagnostic.23
Rarely, colonoscopy can reveal ulcerations and a lack of the “cushion sign,” which may lead to the impression of malignant disease as in the case of our patient. Katsinelos et al24
described 11 lesions that demonstrated malignant features on colonoscopy but were proved ultimately to be benign lipomas on histopathology examination.
Preoperative diagnosis of gastrointestinal lipomas can be difficult when it presents as signs and symptoms suggesting malignant disease that cannot be excluded definitively through imaging or biopsy alone. The greatest clinical importance of intestinal lipoma is its potential to be confused with malignant colonic neoplasm.16,17
Therefore, histopathologic evaluation is the gold standard diagnosis. Immediate surgical intervention is mandatory in cases of obstruction, intussusception, perforation, or massive hemorrhage16
with the last sign being seen in our patient.
Several operative and nonoperative techniques have been described, including laparotomy, mini-laparotomy, and laparoscopy to perform enucleation, colostomy, excision, or segmental colonic resection of lipomas.25–27
Among the nonoperative techniques, endoscopic removal of symptomatic lipomas is controversial due to the inefficient conduction of electric current through adipose tissue. This inefficiency results in an unacceptably high rate of complications, including perforation or hemorrhage.25,28
Previous case reports have demonstrated that ileocecal valve lipomas present most commonly as intussusception1–3
Only one of these earlier cases was managed by laparoscopic resection.1
To our knowledge, laparoscopic resection has not been utilized in the setting of acute hemorrhage secondary to an ileocecal valve lipoma. However, given that lipomas disbursed throughout other regions of the large intestine have been resected successfully through laparoscopy,27,29
laparoscopic resection may now be considered an excellent, minimally invasive option for the treatment of ileocecal valve lipomas presenting as intussusception, volvulus, or hemorrhage.