Ileocecal Valve Lipoma With Refractory Hemorrhage
Linda A. Dultz, MD, MPH, Brant W. Ullery, MD, Huan Huan Sun, MD, Tara L. Huston, MD,
Soumitra R. Eachempati, MD, Philip S. Barie, MD, MBA, Jian Shou, MD
Background: Lipomas are the most common benign
mesenchymal tumors of the gastrointestinal tract, with the
colon being the most prevalent site. Intestinal lipomas are
usually asymptomatic. Tumors ?2 cm in diameter may
occasionally cause nonspecific symptoms, including
change in bowel habits, abdominal pain, or rectal bleed-
ing, but with resection the prognosis is excellent. Herein,
we describe the case of an elderly male who presented
with painless hematochezia.
Methods: Both colonoscopy and computed tomography
of the abdomen and pelvis confirmed the presence of a
mass near the ileocecal valve. Because of continuing
bleeding, the patient required laparoscopic-assisted right
hemicolectomy to resect the mass.
Results: Both gross and microscopic pathology were con-
sistent with lipoma at the ileocecal valve.
Conclusion: Previous cases of ileocecal valve lipomas
have been reported in the English literature, with the
majority presenting as intussusception or volvulus. We
present a rare case of an ulcerated ileocecal valve lipoma
presenting as lower gastrointestinal bleeding that was
treated successfully with laparoscopic resection.
Key Words: Lipoma, Ileocecal valve, Rectal bleeding.
Lipomas are the most common benign mesenchymal tu-
mors of the gastrointestinal tract. Distribution of alimen-
tary lipomas demonstrates a predilection for the colon, but
they may originate anywhere in the gastrointestinal tract,
from the hypopharynx to the rectum. Often asymptomatic
and detected incidentally at the time of colonoscopy or
surgery, lipomas ?2 cm in diameter may occasionally
cause nonspecific symptoms, including change in bowel
habits, abdominal pain, or rectal bleeding. Diagnosis of
gastrointestinal lipomas may involve barium enema,
colonoscopy, or computed tomography (CT). Diagnosis is
notoriously difficult given that malignant disease cannot
be excluded definitively through imaging or biopsy alone.
A wide range of operative and nonoperative techniques
has been utilized for resection. Few cases of lipoma have
been reported to date with origin at the ileocecal valve,
the majority of which have presented as intussuscep-
tion1–3or volvulus.4We describe a rare case of an ulcer-
ated ileocecal valve lipoma associated with lower gastro-
intestinal bleeding that was significant enough to require
urgent laparoscopic resection.
A 77-year-old male with a history of diabetes mellitus,
hypertension, coronary artery disease, aortic valve re-
placement, and coronary artery bypass grafting, who was
therapeutic on warfarin, presented to his gastroenterolo-
gist with 2 days of painless hematochezia. He denied
similar prior episodes of rectal bleeding. Outpatient
colonoscopy performed at that time revealed a 6-cm cecal
mass with mucosal necrosis at the ileocecal valve, as well
as a small ulcer at the hepatic flexure. Given the colono-
scopic findings, the patient was transported urgently to
our emergency department.
Upon presentation, the patient was in no acute distress
with a core temperature of 36.4oC, heart rate of 73 beats/
min, blood pressure of 135/91 mm Hg, and respiratory
rate of 18 breaths/minute. His abdomen was soft, non-
tender, and nondistended with no evidence of peritoneal
irritation. Computed tomography of the abdomen and
pelvis with oral and intravenous contrast revealed a
Departments of Surgery and Public Health, Weill Cornell Medical College, New
York, New York (all authors).
Address correspondence to: Dr. Jian Shou, Department of Surgery, Weill Cornell
Medical College, 525 East 68th Street, New York, NY 10065, USA. Telephone: 212
746 5446, Fax: 212 746 7291, E-mail: email@example.com
© 2009 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
1.9-cm x 1.5-cm lesion within the cecum (Figure 1). The
patient was admitted for hemodynamic monitoring, trans-
fusion, and surgical resection of the ileocecal mass.
The patient received vitamin K and 2 units of fresh frozen
plasma for reversal of the effect of warfarin. Nonetheless,
hematochezia continued with a steady decrease in hemat-
ocrit from 43% to 39% over a 24-hour period. On hospital
day 2, he underwent an uncomplicated laparoscopic-as-
sisted right hemicolectomy and ileo-transverse colostomy.
Pathology revealed a 3.5-cm x 2.0-cm x 1.5-cm mass at the
ileocecal valve (Figure 2). The yellow, homogeneous cut
surfaces and the microscopic evaluation (Figure 3) were
both consistent with lipoma of the ileocecal valve. The
postoperative course was unremarkable. The patient re-
gained bowel function by postoperative day 4 and was
discharged the following day.
Gastrointestinal lipomas are benign lesions arising from the
adipocytes within the intestinal submucosa5with the first
case reported by Bauer in 1757.6With a reported incidence
of 0.2% to 4.4%, lipomas are the third most common benign
colonic neoplasm following hyperplastic and adenomatous
polyps.7–9Lipomas are found most commonly in the colon,
with the highest frequency found in the ascending colon and
cecum followed by the transverse colon, descending colon,
sigmoid, and least often the rectum.10Despite the propensity
for colonic distribution, lipomas can occur anywhere along
the alimentary tract, including the hypopharynx, stomach,
small bowel, and esophagus.11,12When confined to the co-
lon, 90% of these lesions are localized to the submucosa;
however, a few reports have suggested an origin in the
subserosal plane.7,10These tumors are more prevalent in
women and are typically discovered during the fifth or sixth
decade of life.13–15
Figure 2. Intraoperative photograph with cecum opened to
reveal a 3.5-cm ? 2.0-cm ? 1.5-cm tumor (bottom arrow) and
ileocecal valve (top arrow).
Figure 3. Histopathology of lipoma: Hematoxylin and eosin
stain (20? magnification) reveals a circumscribed collection of
Figure 1. CT image of mass preoperatively, demonstrating a
1.9-cm ? 1.5-cm lesion within the cecum (arrow), measuring -80
Hounsfield units, consistent with adipose tissue.
Lipomas tend to be solitary, spherical, and smooth lesions.
They vary in size and can be sessile or pedunculated. Cases
of multiple lesions have been reported.10,16Lipomas are
generally asymptomatic and are identified most commonly
as incidental findings during colonoscopy, surgery, or au-
topsy. In the minority of patients who do present with symp-
toms, the lesions tend to be ?2 cm in diameter, as in the
present case. Common symptoms include constipation, di-
arrhea, colicky abdominal pain, or lower gastrointestinal
bleeding.7,17,18Abdominal pain may be associated with in-
termittent intussusception, whereas gastrointestinal bleeding
is secondary to ulceration of the overlying mucosa.16In rare
cases, patients can present with dramatic clinical symptom-
atology that requires urgent operative intervention,4usually
for intussusception or acute hemorrhage.6Our patient pre-
sented with hematochezia likely secondary to the combina-
and the patient’s anticoagulation regimen.
A variety of imaging modalities are available to assist in
the preoperative diagnosis of gastrointestinal lipoma. Bar-
ium enema shows colonic lipomas as ovoid, well-delin-
eated, and smooth radiolucent masses.10A “squeeze sign”
can also be noted, which indicates a change in size and
shape of the lesion due to peristalsis.19Unfortunately,
barium enema does not yield a definitive diagnosis. Com-
puted tomography scanning is a second modality that
provides a more definitive diagnosis in uncomplicated
cases, where lipomas appear as sharply demarcated ovoid
lesions with absorption densities of -40 to -120 Hounsfield
units.20,21In the present case, CT demonstrated a cecal
mass and provided a likely diagnosis. Lastly, endoscopy is
a third diagnostic tool with 2 typical findings: “Tenting” is
described when the mucosa overlying the lipoma is easily
retracted away from the mass with biopsy forceps, and a
“cushion sign” is present when the forceps produces a
soft, cushioning indentation when applied to the lipoma.22
Due to the submucosal location of these lipomas, superficial
colonoscopic biopsies are often nondiagnostic.23Rarely,
colonoscopy can reveal ulcerations and a lack of the
“cushion sign,” which may lead to the impression of ma-
lignant disease as in the case of our patient. Katsinelos
et al24described 11 lesions that demonstrated malignant
features on colonoscopy but were proved ultimately to be
benign lipomas on histopathology examination.
Preoperative diagnosis of gastrointestinal lipomas can
be difficult when it presents as signs and symptoms
suggesting malignant disease that cannot be excluded
definitively through imaging or biopsy alone. The great-
est clinical importance of intestinal lipoma is its poten-
tial to be confused with malignant colonic neo-
plasm.16,17Therefore, histopathologic evaluation is the
gold standard diagnosis. Immediate surgical interven-
tion is mandatory in cases of obstruction, intussuscep-
tion, perforation, or massive hemorrhage16with the last
sign being seen in our patient.
Several operative and nonoperative techniques have been
described, including laparotomy, mini-laparotomy, and
laparoscopy to perform enucleation, colostomy, excision,
or segmental colonic resection of lipomas.25–27Among the
nonoperative techniques, endoscopic removal of symp-
tomatic lipomas is controversial due to the inefficient
conduction of electric current through adipose tissue. This
inefficiency results in an unacceptably high rate of com-
plications, including perforation or hemorrhage.25,28
Previous case reports have demonstrated that ileocecal
valve lipomas present most commonly as intussuscep-
tion1–3or volvulus.4Only one of these earlier cases was
managed by laparoscopic resection.1To our knowledge,
laparoscopic resection has not been utilized in the setting
of acute hemorrhage secondary to an ileocecal valve li-
poma. However, given that lipomas disbursed throughout
other regions of the large intestine have been resected
successfully through laparoscopy,27,29laparoscopic resec-
tion may now be considered an excellent, minimally in-
vasive option for the treatment of ileocecal valve lipomas
presenting as intussusception, volvulus, or hemorrhage.
We present a case of ileocecal valve lipoma in a patient
who presented with acute gastrointestinal hemorrhage.
Colonoscopy revealed a necrotic mass in the proximal
ascending colon. The patient required urgent laparo-
scopic-assisted right hemicolectomy to control bleeding.
After an extensive literature review, it was found that the
majority of intestinal lipomas present as colonic lipomas
with either intussusceptive or obstructive symptoms. We
believe this is a very rare case of an ileocecal valve lipoma
presenting as ulcerations and necrosis leading to acute
hemorrhage and urgent resection.
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