Endoscopy 2011; 43: E96-E97
DOI: 10.1055/s-0030-1256055
Unusual cases and technical notes

© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic treatment of a giant pedunculated angiolipofibroma of the distal duodenum

J.  Bartova1 , J.  Bures1 , M.  Podhola2 , S.  Rejchrt1 , I.  Tacheci1 , M.  Kopacova1
  • 12nd Department of Medicine, Charles University in Praha, Faculty of Medicine at Hradec Kralove, University Teaching Hospital, Hradec Kralove, Czech Republic
  • 2The Fingerland Department of Pathology, Charles University in Praha, Faculty of Medicine at Hradec Kralove, University Teaching Hospital, Hradec Kralove, Czech Republic
Further Information

Publication History

Publication Date:
18 March 2011 (online)

Dual antiplatelet therapy (with clopidogrel and aspirin) may be complicated by severe gastrointestinal bleeding [1]. It may unmask an underlying pathology that has been silent so far. Small intestinal bleeding is the most frequent indication for double-balloon enteroscopy (DBE), both for diagnosis and treatment [2] [3]. DBE is feasible even for polypectomy of large small-intestinal polyps (e. g. hamartomas) [4]. We present an unusual case of successful endoscopic removal of a giant angiolipofibroma.

A 73-year-old man on dual antiaggregation therapy was investigated because of recurrent gastrointestinal bleeding requiring repeated blood transfusions (8 units over 3 months). The patient underwent gastroscopy and colonoscopy elsewhere with normal findings, and capsule enteroscopy with suspicion of small-bowel arteriovenous malformations (AVMs). He was subsequently referred to our department for DBE. However, no AVMs were revealed at DBE. Surprisingly, a finger-like giant polyp growing from the distal part of the duodenum reaching the proximal jejunum was found. The length of the polyp was 12 cm and its diameter 2 cm. Because of the patient’s serious comorbidity, we decided to remove the polyp endoscopically ([Video 1]).


Quality:

Video 1 An Endoloop was put over the polyp and secured by two clips. Pure coagulation current was used for cutting. Polypectomy took 8 minutes. Mild bleeding was controlled by another two Endoloops placed on the base and additional argon plasma coagulation.

The polyp was extracted for histology ([Figs. 1] and [2]).

Fig. 1 A giant polyp immediately after endoscopic polypectomy and its retrieval for histology. Note the large-caliber central vessel.

Fig. 2 Longitudinal section of the angiolipofibroma after its fixation in 10 % buffered neutral formalin. Note the large caliber of the vessels.

The final diagnosis was angiolipofibroma ([Fig. 3]).

Fig. 3 Histology of angiolipofibroma. A well-demarcated lesion underlies the mucosa. The neoplasm is composed of fat, fibrous tissue, and prominent congested vessels. (Hematoxylin and eosin staining; original magnification × 100.)

There were no complications after the procedure ([Fig. 4]) and subsequent follow-up was uneventful.

Fig. 4 Control endoscopy 9 days after polypectomy. The healing base is seen in the distal duodenum (arrow), one Endoloop is still in the right position.

Angiolipofibroma of the gastrointestinal tract is extremely rare. We found only one similar case in the available literature [5]. A giant pedunculated angiolipofibroma of the esophagus in a 62-year-old patient caused slowly deteriorating dysphagia but did not bleed. This was diagnosed by computed tomography and resolved by surgery [5].

Endoscopic polypectomy of giant small-intestinal polyps is a possible alternative to surgery in polymorbid patients. An experienced endoscopist, a safe design of the procedure, and preventive measures (availability of appropriate urgent surgery in case of complications) are necessary conditions.

References

  • 1 Roy P, Bonello L, Torguson R et al. Impact of “nuisance” bleeding on clopidogrel compliance in patients undergoing intracoronary drug-eluting stent implantation.  Am J Cardiol. 2008;  102 1614-1617
  • 2 Kopacova M, Tacheci I, Rejchrt S et al. Double balloon enteroscopy and acute pancreatitis.  World J Gastroenterol. 2010;  16 2331-2340
  • 3 Rejchrt S, Kopacova M, Tacheci I et al. Interventional double balloon endoscopy for Crohn’s, gastrointestinal bleeding, and foreign body extraction.  Tech Gastrointest Endosc. 2008;  10 101-106
  • 4 Kopacova M, Bures J, Ferko A et al. Comparison of intra-operative enteroscopy and double balloon enteroscopy in the diagnosis and treatment of Peutz–Jeghers syndrome.  Surg Endosc. 2010;  24 1904-1910
  • 5 Koischwitz D. Computertomographische Diagnose eines monströsen gestielten Angiolipofibroms des Ösophagus. [Computed tomographic diagnosis of a monstrous pedunculated angiolipofibroma of the esophagus.]  Fortschr Röntgenstr. 1988;  149 105-107

M. KopacovaMD, PhD 

Second Department of Medicine
Charles University Teaching Hospital

Sokolska 581
500 05 Hradec Kralove
Czech Republic

Fax: +420-495-834785

Email: kopaemar@fnhk.cz

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