Duodenal Lipoma Causing Intussusception and Gastric Outlet Obstruction

CASE REPORT

A 68-year-old woman, with a known history of duodenal lipoma, presented with 1 day of melena and upper abdominal pain without vomiting. A 5.5-cm lipoma in the duodenal bulb (D1) had been confirmed 5 years ago, after incidental detection at esophagogastroduodenoscopy and subsequent biopsy. An endoscopic ultrasound 5 months before this presentation found the lesion unchanged, so no further management had been initiated (Figure 1).

Figure 1.

Endoscopic view of the first part of the duodenum (medial wall of the duodenal bulb) revealing a 6-cm duodenal lipoma with characteristic features of the a pedunculated mass and smooth overlying mucosa.

On admission, the patient was hypotensive, and digital rectal examination revealed melena. Laboratory tests showed normal hemoglobin 7.63 g/dL and mildly elevated urea 57.7 mg/dL with creatinine 0.70 mg/dL. Given her past medical history, ulceration of the lipoma was suspected, and a proton pump inhibitor started.

Esophagogastroduodenoscopy demonstrated a large gastric residue with a deformed antrum, which could not be straightened, and the procedure was abandoned. Computed tomography scan revealed intussusception with D1 lipoma acting as lead point (Figure 2). Because endoscopic access was completely obstructed by this, the patient proceeded to a laparoscopic resection via duodenostomy and primary repair (Figure 3). Histology confirmed a 175 g, 105 × 62 × 54 mm submucosal lesion composed of mature adipocytes with focal areas of fat necrosis (Figure 4). She remained well at the subsequent 6-month follow-up.

Figure 2.

Computed tomography scan of the abdomen in coronal view, showing a large D1 segment duodenal lipoma causing intussusception of the pylorus and distal stomach into the D2 segment of the duodenum.

Figure 3.

Laparoscopic image from the umbilical port pointing cephalad. The intussuscepted lipoma could not be reduced with traction, requiring opening of the duodenum and flipping the medial submucosal mass out of the second part of the duodenum. This image shows the lipoma (L) protruding from the open duodenum (D1 and D2) before stapling.

Figure 4.

Macroscopic pathology specimen showing a thinly encapsulated, yellow fatty lipoma with an overlying tan-brown mucosa. Scale marked at 10-mm intervals.

Lipomas are benign tumors consisting of mature fat cells which may occur in any organ, affecting men and women equally.¹ In the gastrointestinal tract, 90% arise from the submucosa; the remainder are either subserosal or intramucosal.² The most common sites are the colon (64% of gastrointestinal lipomas), followed by the ileum and jejunum (26%), whereas duodenal lipomas are uncommon (4%); a recent systematic review found only 59 cases of duodenal lipomas previously published.^2,3 Of these, 20% were located in the D1, 50% in the descending part (D2), 16% in the horizontal part (D3), and 9% in the ascending part (D4), with 5% not specified.¹ Duodenal lipomas are usually asymptomatic and rarely present with complications.¹ Symptoms generally only occur with lipomas ≥4 cm and include abdominal pain, bleeding, and gastric outlet obstruction. However, intussusception such as in our case is an especially rare presentation, with case reports only, because most of the duodenum is fixed retroperitoneally except for the first part. No guidelines exist for the management of these benign tumors, but often they are observed unless symptomatic, which requires resection. Duodenal lipomas can present with bleeding, intussusception, and bowel obstruction. Although endoscopic options are available, management may require surgery because of the size or location.

DISCLOSURES

Author contributions: D. Tjandra wrote the manuscript and is the guarantor. B. Knowles, P. Simkin, and S. Kranz provided the images. S. Kranz and A. Metz revised the manuscript.

Financial disclosure: None to report.

Informed consent was obtained for this case report.