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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 2  |  Issue : 2  |  Page : 79-81

Submucosal colonic lipoma presenting with acute abdomen due to intestinal obstruction


1 Department of Pathology, Medical College, Kolkata, West Bengal, India
2 Department of Surgery, Calcutta National Medical College, Kolkata, West Bengal, India

Date of Web Publication21-Sep-2013

Correspondence Address:
Santosh Kumar Mondal
"Teenkanya Complex", Flat 1B, Block B, 204 R N Guha Road, Dumdum, Kolkata - 700 028, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4855.118666

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  Abstract 

Colonic lipomas are uncommon neoplasms. These tumors rarely produce symptoms. However, we encountered a middle-aged man presenting with features of acute intestinal obstruction. On laparotomy, a hard, irregular mass was identified at splenic flexure. Histological evaluation proved the mass to be a submucosal lipoma. We are presenting this case along with relevant discussions to underscore the fact that colonic lipomas can present as acute abdomen.

Keywords: Colon, lipoma, submucosal, symptomatic


How to cite this article:
Mondal SK, Sengupta S, Mallick MG, Ghosh N. Submucosal colonic lipoma presenting with acute abdomen due to intestinal obstruction. J Acad Med Sci 2012;2:79-81

How to cite this URL:
Mondal SK, Sengupta S, Mallick MG, Ghosh N. Submucosal colonic lipoma presenting with acute abdomen due to intestinal obstruction. J Acad Med Sci [serial online] 2012 [cited 2019 Jul 22];2:79-81. Available from: http://www.e-jams.org/text.asp?2012/2/2/79/118666


  Introduction Top


Lipomas are the commonest benign mesenchymal tumors of the gastrointestinal tract. However, colonic involvement occurs uncommonly. Until 2001, only 275 such cases were reported in the English literature. [1] Commonly colonic lipomas are small (less than 2 cm in diameter), asymptomatic, and discovered incidentally. However, larger tumors may produce symptoms varying from alteration in bowel habits, rectal bleeding, abdominal pain to acute or subacute obstuctions. [2],[3]

Preoperative diagnosis of these tumors is often difficult. Even with available sophisticated imaging techniques such as computed tomography (CT) scan and magnetic resonance imaging (MRI), definitive diagnosis is only possible based on histopathological evaluation. [4],[5] Endoscopic resection is therapy of choice for small colonic lipomas. However, larger tumors often require open surgery to relieve symptoms or exclude malignancy. [5],[6]

This study reports a case of colonic lipoma of splenic flexure presenting with acute abdomen.


  Case Report Top


A 42-year-old male patient presented with features of acute abdomen characterized by vomiting, abdominal distension, pain, and constipation. There was past history of a similar episode 4months back, which was treated conservatively. On examination, the abdomen was found to be tense, distended with evidence of hyperperistalsis. Ultrasonography failed to detect any mass/tumor. A decision of explorative laparotomy was taken as no improvement occurred after conservative therapy.

On exploration, dilated small and large bowel loops up to the splenic flexure were found. There was a hard, irregular mass at the splenic flexure; no evidence of local or distantdissemination of the disease was found. A presumptive diagnosis of colonic carcinoma was made and standard left hemicolectomy with end-to-end anastomosis was performed. The patient recovered uneventfully.

Histopathological Findings

Specimen of colostomy with growth was subjected to histopathological evaluation. Gross examination showed a large (4.0 cm × 3.5 cm × 2.0 cm), pedunculated, soft to firm globular mass in the splenic flexure with focal ulcerations [Figure 1].
Figure 1: Gross photograph of the tumor showing a yellowish fatty mass in the splenic flexure

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Microscopically, the tumor was present in the submucosa and the overlying mucosa showed focal ulceration. The tumor was composed of mature adipocytes separated by fibrous septa. Nuclear atypia, mitosis, and lipoblast were absent. Congestion and mild infiltration of inflammatory cells were also noted within the tumor [Figure 2.]. Thus, a final diagnosis of well-differentiated lipoma was rendered.
Figure 2: Microphotograph showing the tumor composed of mature adipocytes and separated by fibrous septa. Congestion and mild infiltration of inflammatory cells were also noted within the tumor

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  Discussion Top


In 1757, Bauer first described lipomas of the gastrointestinal tract. [7] Reported incidence in the large bowel varies from 0.15 to 4.4%. Colonic lipomas are diseases that occur in the middle age, with a slight female prepondarance. [6],[7] Lesions are usually solitary. Multiple tumors occur in only 6.1% cases. [2] Caecum and ascending colon are commonly involved. [7] Lipomas of the colon are usually small, well-circumscribed, submucosal, pedunculated or sessile, polypoid neoplasms. [7] Larger lesions are often reported. [2],[5] Subserosal or intramucosal variants account for only 10% of the cases. [8]

Colonic lipomas are commonly asymptomatic. Only 6% cases produce symptoms. Neoplasms larger than 3 cm in diameter are more likely to produce symptoms. [5] Commonest presenting symptoms are rectal bleeding (54.5%), followed by abdominal pain (42.4%), and alteration of bowel habit (24.2%). [2] Other rare presentations include intestinal obstruction, perforation, intussusception, and rectal prolapse. [1],[4],[5]

Diagnosis of colonic lipoma is quite difficult. Majority (46%) of the lesions are discovered incidentally. [5] However, large tumors may be mistaken for more serious lesions due to variable presentations and rare occurrences. [2],[3] CT scan and MR are preferred in this setup because of typical imaging characteristics for fatty tissue, but are not confirmatory. [9] Barium enema can identify the colonic mass as smooth and radiolucent with change in size and shape due to peristalsis (squeeze sign). [3],[5] Colonoscopy is an important tool for diagnosis. Colonic lipomas less than 2 cm in diameter also can be removed by this process. [10] Characteristic findings of the neoplasms as evidenced during endoscopy include tentsign (elevation of the mucosa overlying the polyp with biopsy forceps), cushion sign (indentation of lipoma on pressing with biopsy forceps), and naked fat sign (extrusion of fat from biopsied tissue). [7],[11] However, larger symptomatic lesions require open surgery with polypectomy or more extensive resection for diagnosis as well as management. [8]

Final diagnosis of the tumors can only be possible after histological examination. Intraoperative frozen section examination can reduce unnecessary extensive surgery. [2] Almost all the tumors show features of well-differentiated lipoma with enhanced lobulations and frequent presence of congestion, inflammatory changes, or surface ulcerations. [2],[5] Rare cases may show histology of atypical lipomas with pseudosarcomatous features. [12] Colonic lipomas have excellent prognosis. Malignant change or recurrence after excision has still not been reported. [2],[5],[12]

In conclusion, in this study, we have described a rare presentation of an uncommon tumor mimicking a more serious lesion. We emphasize that the possibility of submucosal colonic lipoma should be considered in the differential diagnosis of intestinal obstruction due to neoplasms.

 
  References Top

1.Franc-Law JM, Bégin LR, Vasilevsky CA, Gordon PH. The dramatic presentation of colonic lipomata: Report of two cases and review of the literature. Am Surg 2001;67:491-4.  Back to cited text no. 1
    
2.Jiang L, Jiang LS, Li FY, Ye H, Li N, Cheng NS, et al. Giant submucosal lipoma located in the descending colon: A case report and review of the literature. World J Gastroenterol 2007;13:5664-7.  Back to cited text no. 2
    
3.Tascilar O, Cakmak GK, Gün BD, Uçan BH, Balbaloglu H, Cesur A, et al. Clinical evaluation of submucosal colonic lipomas: Decision making. World J Gastroenterol 2006;12:5075-7.  Back to cited text no. 3
    
4.Buetow PC, Buck JL, Carr NJ, Pantongrag-Brown L, Ros PR, Cruess DF. Intussuscepted colonic lipomas: Loss of fat attenuation on CT with pathologic correlation in 10 cases. Abdom Imaging 1996;21:153-6.  Back to cited text no. 4
    
5.Ghidirim G, Mishin I, Gutsu E, Gagauz I, Danch A, Russu S. Giant submucosal lipoma of the cecum: Report of a case and review of literature. Rom J Gastroenterol 2005;14:393-6.  Back to cited text no. 5
    
6.Chung YF, Ho YH, Nyam DC, Leong AF, Seow-Choen F. Management of colonic lipomas. Aust N Z J Surg 1998;68:133-5.  Back to cited text no. 6
    
7.Ryan J, Martin JE, Pollock DJ. Fatty tumours of the large intestine: A clinicopathological review of 13 cases. Br J Surg 1989;76:793-6.  Back to cited text no. 7
    
8.Bardají M, Roset F, Camps R, Sant F, Fernández-Layos MJ. Symptomatic colonic lipoma: Differential diagnosis of large bowel tumors. Int J Colorectal Dis 1998;13:1-2.  Back to cited text no. 8
    
9.Liessi G, Pavanello M, Cesari S, Dell'Antonio C, Avventi P. Large lipomas of the colon: CT and MR findings in three symptomatic cases. Abdom Imaging 1996;21:150-2.  Back to cited text no. 9
    
10.Kim CY, Bandres D, Tio TL, Benjamin SB, Al-Kawas FH. Endoscopic removal of large colonic lipomas. Gastrointest Endosc 2002;55:929-31.  Back to cited text no. 10
    
11.Bahadursingh AM, Robbins PL, Longo WE. Giant submucosal sigmoid colon lipoma. Am J Surg 2003;186:81-2.  Back to cited text no. 11
    
12.Snover DC. Atypical lipomas of the colon. Report of two cases with pseudomalignant features. Dis Colon Rectum 1984;27:485‑8  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2.]



 

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