Spontaneous peeled ileal giant lipoma caused by lower gastrointestinal bleeding: A case report

Abstract

Rationale: Gastrointestinal subepithelial tumors (SETs) with endoscopic features such as ulceration, a red color change, a peeled mucosal layer, and spontaneous bleeding could have malignant potential. However, we encountered a case of a lipoma that presented features different from the generally known features of gastrointestinal SETs. Therefore, we report an interesting rare case of a terminal ileal giant lipoma with a unique feature of spontaneous peeled ulceration on the surface on endoscopy that caused gastrointestinal bleeding.

Patient: An 82-year-old woman with a 1-week history of abdominal pain and hematochezia presented to our hospital.

Diagnoses: Ileocolonoscopy revealed a SET with a peeled surface and erythematous and ulcerative mucosal changes as well as exposed a submucosal mass at the terminal ileum. Macroscopically, the lesion appeared as a yellowish pedunculated polypoid mass measuring 3 × 2 cm with a peeled mucosal ulceration. Histopathological findings revealed a submucosal lipoma of the terminal ileum.

Intervention: We thought that the endoscopic finding indicated malignant SETs or those with malignant potential rather than benign SETs. Therefore, the patient underwent an elective laparoscopic ileocecectomy.

Lessons: We encountered a lipoma that did not present with the typical features of gastrointestinal SETs. Our findings suggest that clinicians should consider that benign SETs in the terminal ileum may present with various endoscopic findings similar to those of malignant SETs, which can cause fatal symptoms and signs.

Figure 1

Endoscopic view of the terminal ileal mass. (A) Side view of an endoscopy. (B) Top view of an endoscopy. (A, B) The ileocolonoscopy revealing that more than half of the surface of the terminal ileal mass was peeled, and that ulcerative mucosal changes had formed, and that the submucosal tissue was exposed at the terminal ileum.

Figure 2

Diagnostic imaging findings. (A) Small bowel study. Enterography using gastrografin showing a very radiolucent, well-circumscribed, intramural filling defect compressing the terminal ileum but no evidence of obstruction. (B, C) The contrast-enhanced portal venous CT image (transverse (B), coronal (C) image). The abdominopelvic CT scan showing a round, smooth, and well-demarcated 30-mm tumor with fat attenuation in the submucosal layer of the terminal ileum. These are well-circumscribed intraluminal masses with homogenous fat attenuation. (D–F) PET-CT image. PET revealed slightly increased 18-FDG uptake in the terminal ileum. CT = computed tomography, FDG = F-fluoro-2-deoxy-D-glucose, PET = positron emission tomography.

Figure 3

Histopathology of the terminal ileal tumor. (A) The macroscopic view of the resected specimen demonstrating a round reddish tumor with a peeled mucosal surface. (B) In the longitudinal section of the tumor, a large yellow pedunculated polypoid mass measuring 3 × 2 cm is seen that resembles lipoma. (C, D) Microscopic findings revealing the submucosal lipoma of small intestine. The tumor is microscopically composed of mature fat. Mature adipocytes with compact eccentric nuclei and abundant lipid-filled cytoplasm are evident in this lipoma [hematoxylin and eosin staining: ×4 (C) and ×40 (D)].