A 66-year-old man presented with fatigue and acute upper gastrointestinal bleeding
(hemoglobin 92 g/L). He had melena but no signs of hematemesis. Upper gastrointestinal
endoscopy revealed a 35 × 15-mm large polypoid lesion with multiple ulcerations in
the second part of the duodenum ([Fig. 1]). No biopsy samples were taken due to the risk of bleeding. The diagnosis was unclear
and the patient underwent endoscopic ultrasound, which demonstrated a hyperechoic
lesion measuring 11 × 19 mm in diameter in the submucosa in the duodenal wall with
intact muscularis propria ([Fig. 2]), suggestive of a lipoma. A subsequent capsule endoscopy excluded distal causes
of bleeding in the small intestine. Next, the lesion was removed endoscopically using
an endoloop and snare without any complication ([Fig. 3]). The resected lesion exhibited multiple ulcerated areas ( [Fig.4]). Histological examination demonstrated a duodenal lipoma with large blood vessels
in contact with these ulcerated areas ([Fig. 5]).
Fig. 1 Endoscopic view of a 3-cm long polypoid lesion with multiple ulcerations in the second
part of the duodenum in a 66-year-old man with fatigue and acute upper gastrointestinal
bleeding.
Fig. 2 Endoscopic ultrasound showing a hyperechoic lesion (11 × 19 mm) originating from
the submucosa in the duodenal wall.
Fig. 3 a The lesion was removed using an endoloop and snare (endocut mode effect 2 and forced
coagulation effect 2, 30 W, VIO 300 D; ERBE Elektromedizin, Tubingen, Germany). b The resection site 24 hours after polypectomy.
Fig. 4 The resected specimen showing multiple ulcerated areas.
Fig. 5 Histological section from the lesion showing adipose cells compatible with duodenal
lipoma and large blood vessels in contact with the ulceration (arrow).
Duodenal lipomas are extremely rare and constitute only one in 600 benign tumors of
the gastrointestinal tract [1]. Duodenal lipomas are usually asymptomatic but larger
ones can, in rare cases, cause abdominal pain, intestinal obstruction, or hemorrhage
[2, 3]. Symptomatic duodenal lipomas should be removed. The current recommendation
is endoscopic excision, unless this is technically difficult and warrants surgical
excision. Nonetheless, this unusual case with a duodenal lipoma causing upper gastrointestinal
bleeding underlines the clinical importance of endoscopic ultrasound in the workup
of patients with unclear submucosal lesions in the gastrointestinal tract.
Endoscopy_UCTN_Code_CCL_1AB_2AZ
