A Rare Cause of Upper GI Bleed Caused by Duodenal Lipoma

Abstract

Lipomas are slow growing masses consisting of mature fat tissue that usually appear in the subcutaneous tissue of the trunk and extremities. Lipomas of the gastrointestinal tract are uncommon but occasionally when found, usually appear in the colon with duodenal lipomas being rare. This case presents a patient with a large duodenal lipoma with ulceration causing brisk upper GI bleeding. A 76 year-old female with past medical history of hypertension presented with dyspnea on exertion since four days. It was associated with chest discomfort, dizziness and relieved on rest. She also reported intermittent black stools of unknown duration but no bright red blood or vomiting. There was no history of NSAID or steroid use. Her exam was significant for hypotension and pallor. She did not exhibit any abdominal tenderness. Rectal exam revealed heme positive brown stool. Her labs revealed critical hemoglobin and hematocrit of 3.7 gm/dL and 13.5%. CT of the abdomen showed a giant 10.7x 7.4 x 7.8 cm intraluminal lipoma in the second part of the duodenum with its stalk noted to be in the upper part of the duodenum. There were focal irregularities noted in the anterior portion suggesting ulceration but no contrast extravasation to suggest active bleeding. The patient was admitted to the ICU for aggressive resuscitation with blood products and continued supportive care. EGD was done, which revealed a large duodenal bulb mass with multiple areas of superficial ulceration that may have served as a bleeding source. There were no stigmata of active bleeding. The biopsy report after discharge revealed that the mass had evidence of inflammatory changes and negative for malignancy. Due to its size and risk of further bleeding, surgical removal was recommended but the patient refused. The presence of duodenal lipoma is underreported in the literature, with peak incidence around the 5th and 7th decade of life. Approximately 64% of GI tract lipomas are found in the colon with only 4% seen in the duodenum. They are mostly asymptomatic and usually present as upper GI bleeding. Other clinical manifestations include ulceration, intussusceptions, or bowel obstruction. CT scan, EUS and MRI can be used for diagnosis with confirmation obtained with biopsy. The management depends on the size and symptoms. Larger GI lipomas requiring surgical resection and small lipomas can safely be treated with snare polypectomy via endoscopy. If resected the diagnosis should be confirmed histologically.2491_A Figure 1. A transverse view of CT Abdomen showing: A giant intraluminal lipoma in the second part of the duodenum, measuring 10.7 cm x 7.4 cm x 7.8 cm (white arrow). There is irregularity of the anterior margin near the stalk of the lipoma, which could suggest underlying ulceration (red arrow).2491_B Figure 2. A coronal view of CT Abdomen showing:: A giant intraluminal lipoma in the second part of the duodenum, measuring 10.7 cm x 7.4 cm x 7.8 cm (white arrow).2491_C Figure 3. Endoscopic image of the large duodenal bulb mass with multiple areas of ulceration.