Obscure gastrointestinal bleeding caused by intestinal lipomatosis: double-balloon endoscopic and laparoscopic views

A 52-year-old white man without co-morbidities presented with a 6-year history of recurrent abdominal pain and episodes of melena twice a week for the past year. He was started on oral iron sulfate supplements and had already received a blood transfusion.

Findings from physical examination were normal. The hemoglobin level was 10.8 g/dL. Gastroduodenoscopy and colonoscopy revealed several smooth sessile and pedunculated lesions covered by normal mucosa, which are characteristics of lipomas, and with no signs of bleeding. Double-balloon endoscopy (DBE) revealed innumerable similar subepithelial lesions, measuring 1 – 4 cm in diameter, throughout the entire small bowel ([Video 1]). In the distal jejunum, multiple pedunculated lesions were seen, with twisted pedicles, superficial erosion, and covered by fibrin, suggestive of vascular damage ([Fig. 1], [Fig. 2]).

Small-bowel endoscopy, demonstrating intestinal lipomatosis, and laparoscopy, showing small-bowel intussusceptions.

Fig. 1 Double-balloon endoscopy showed small-bowel lipomatosis, with twisted pedunculated lesions located in the distal jejunum.

Fig. 2 Pedunculated lesions with signs of ischemia (redness, edema, and apical erosions).

Abdominal computed tomography scan showed multiple hypodense lesions compatible with lipomas, and areas of intussusception with mild proximal small-bowel dilation ([Fig. 3]). The patient underwent laparoscopy, which confirmed irreducible intussusception, and led to minilaparotomy with four enterotomies and resection of multiple lipomas ([Fig. 4], [Fig. 5]). A total of 26 lesions were resected, including some with signs of bleeding. Histopathology confirmed the diagnosis of lipomatosis ([Fig. 6]).

Fig. 3 Abdominal computed tomography scan showing intussusception.

Fig. 4 At laparoscopy, an area of small-bowel intussusception was seen.

Fig. 5 At laparotomy, an area of intussusception was observed.

Fig. 6 Histological analysis of the surgical specimens revealed lipomatosis (hematoxylin and eosin, × 10).

The patient was discharged 3 days after surgery, and at the 5-month follow-up visit he remained asymptomatic with a hemoglobin level of 12.9 g/dL.

Lipomas of the gastrointestinal (GI) tract are benign tumors and are usually solitary; however, they can rarely present as GI lipomatosis [1]. Although mostly asymptomatic, GI lipomas may cause symptoms, including obstruction as a result of intussusceptions, and GI bleeding [2] [3]. Treatment consists of surgical or endoscopic resection. Endoscopic options include mucosal or submucosal resection, unroofing technique, and application of an endoloop or endoclip [4] [5].

This case demonstrated the endoscopic and laparoscopic characteristics of diffuse GI lipomatosis. DBE was essential to the diagnosis, and surgical resection resolved the intussusception and obscure GI bleeding.

Endoscopy_UCTN_Code_CCL_1AC_2AC

Competing interests: None

• References

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