A Rare Cause of Upper Gastrointestinal Bleeding and Its Novel Endoscopic Management

A 64-year-old male presented with a 2-day history of passage of foul-smelling, black-colored stools. He denied any associated symptoms such as postural dizziness, syncope, abdominal pain, hematemesis, and use of nonsteroidal anti-inflammatory drugs or jaundice. He denied history of any addiction and previous comorbidity. On examination, vital signs, general physical assessment, and systemic evaluation were within normal limits. Routine laboratory investigations were normal except a low hemoglobin level of 10.3 g/dL.

Esophagogastroduodenoscopy identified a single, large, submucosal pedunculated polyp with ulcer at its tip, located on the medial wall of the second part of the duodenum (D2) ([Fig. 1A]). Side-viewing endoscopy confirmed the origin of lesion separate from the ampulla of Vater. Histopathological examination of deep mucosal biopsy from the lesion was consistent with the diagnosis of submucosal lipoma. To exclude synchronous colonic polyps, colonoscopy was performed and found to be normal. Abdominal contrast-enhanced computed tomography revealed duodenal submucosal lipoma (size: 2.2 × 1.8 × 2.6 cm), originating from the posteromedial wall of D2 ([Fig. 1B, C]).

Fig. 1 (A) Side-viewing endoscopy image showing normal ampulla (blue arrow) with a large submucosal pedunculated lesion with ulcer on the tip (yellow arrow), arising from the medical wall of the second part of the duodenum (separately from the ampulla). (B and C) Axial and coronal contrast-enhanced computed tomography image with negative oral contrast showing fat density pedunculated lesion (yellow arrows) arising from the posteromedial wall of the second part of the duodenum suggestive of submucosal lipoma.

The lesion was managed endoscopically using a novel “loop and let go” technique. Following submucosal injection of diluted adrenaline saline (1:10,000) at the base of the polyp to achieve elevation, a 30-mm detachable snare endoloop (Olympus, Ligating Device HX-400U-30) was deployed tightly around the base ([Fig. 2A–C]). This facilitated gradual mechanical transection via ischemic necrosis, resulting in eventual autoamputation of the polyp. The procedure was uneventful, and follow-up endoscopy performed after 2 months demonstrated complete resolution of the lesion ([Fig. 3]).

Fig. 2 (A–C) Endoscopic image showing deployment and tightening of the detachable endoloop snare around the polyp stalk creating a ligature.

Fig. 3 Side view endoscopic image showing normal ampulla (blue arrow) with residual linear scar (yellow arrow) at the site of submucosal lipoma.

Duodenal lipoma constitutes 4% of all intestinal lipoma (50% arising from D2) and presents most commonly with melena (in large lesion > 2 cm) at a median age of 62.7 years.[1]

The “loop and let go” technique utilizing detachable endoloop snares[1] [2] [3] offers several notable advantages:

1. It is simpler and less invasive compared to traditional methods.

2. By eliminating the need for electrocautery, this approach reduces the risk of bleeding and perforation.

3. It is both convenient and highly effective.

However, potential limitations of the technique include:

1. The necessity for accurate visualization of the lesion stalk.

2. Technical difficulty when applied to broad-based or sessile lipomas, where the technique is best avoided.

3. Possible failure to retrieve the lesion for histopathological examination.

4. The potential requirement for additional procedures.

Practical implications for endoscopists: The “loop and let go” technique is a safe and effective, minimally invasive approach for symptomatic duodenal lipoma, which produces slow mechanical transection of the lesion without the need for electrocautery, so reducing chances of bleeding or perforation.

Conflict of Interest

None declared.

Patient's Consent

Patient provided informed consent to publish the included information.

• References

• 1 Mousa MI, Al Ghamdi SS, Alsolmi AA, Fakhri AF. Duodenal lipoma as upper gastrointestinal bleeding presentation: case report and review of the literature. Cureus 2023; 15 (01) e33996
• 2 Ivekovic H, Rustemovic N, Brkic T, Ostojic R, Monkemuller K. Endoscopic ligation (“Loop-And-Let-Go”) is effective treatment for large colonic lipomas: a prospective validation study. BMC Gastroenterol 2014; 14: 122
• 3 Gravito-Soares E, Gravito-Soares M, Fraga J, Figueiredo P. Large pedunculated lipoma of the colon: endoscopic resection using “loop-and-let-go” technique. GE Port J Gastroenterol 2018; 25 (05) 268-270

Publication History

Article published online:
15 May 2025