A Rare Cause of Lower Gastrointestinal Bleeding

Abstract

Purpose: Objective: To describe a case of terminal ileal lipoma as a rare cause of gastrointestinal bleeding. Case presentation: A 59-year-old man was admitted with one day history of hematochezia preceded by 2 days of black tarry stools. His medical history included diabetes mellitus, hypertension, peripheral vascular disease and coronary artery disease with coronary artery stent placement requiring chronic anti-platelet therapy. He denied history of abdominal surgeries or recent trauma. On physical examination, the patient was hemodynamically stable and his abdomen was soft and non tender. Laboratory data showed normocytic anemia with a hemoglobin of 8.7 g/dL and a normal platelet count and prothrombin time. An esophagogastroduodenoscopy (EGD) was normal. Colonoscopy showed a submucosal mass of 3 cm of diameter in the distal terminal ileum with a clean base central ulceration (Figure 1) causing partial small bowel obstruction. Multiple cold biopsies from the ulcerative surface of the tumor showed mild mucosal blunting and ulceration. A computed tomography of the abdomen showed a fat density lesion in the distal ileum and no additional lesions in the small bowel. The patient underwent an exploratory laparotomy and excision of the ileal mass. Pathology showed an ulcerated ileal mucosa with an underlying lipoma (Figure 2).[715] Figure 1: Endoscopic view of submucosal mass with clean based ulcer. Figure 2: Pathological findings of lipoma/ adipocytes in the ulcerated terminal ileum.Discussion: Small intestine accounts for about 3-5% of lower gastrointestinal bleeding. Small bowel lipomas involving the ileum are generally asymptomatic. Its deeper location and anatomical tortuosity makes both EGD and colonoscopy difficult. Small Bowel Lipomas larger than 2cm are symptomatic and often require surgery. Conclusion: Terminal ileal lipomas are a rare cause of gastrointestinal bleeding. Most of the symptomatic small bowel lipomas require surgery.