A large symptomatic jejunal subepithelial tumor treated with endoloop-assisted polypectomy using spiral enteroscopy

Jen-Wei Chou; Ken-Sheng Cheng; Ching-Pin Lin

doi:10.5217/ir.2016.14.1.104

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Images of the Issue A large symptomatic jejunal subepithelial tumor treated with endoloop-assisted polypectomy using spiral enteroscopy: Jen-Wei Chou^1,3,4, Ken-Sheng Cheng¹, Ching-Pin Lin^2,3,4; Intestinal Research 2016;14(1):104-105.
DOI: https://doi.org/10.5217/ir.2016.14.1.104
Published online: January 26, 2016

¹Division of Gastroenterology and Hepatology, Department of Internal Medicine, China Medical University Hospital, College of Medicine, China Medical University, Taichung, Taiwan, Republic of China.

²Division of Gastroenterology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung, Taiwan, Republic of China.

³Taiwan Society of Inflammatory Bowel Disease, Taiwan, Republic of China.

⁴Taiwan Association for the Study of Small Intestinal Diseases, Taiwan, Republic of China.

Correspondence to Ching-Pin Lin, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Chung Shan Medical University Hospital, No. 110 Section 1 Chien-Kuo North Road, Taichung 402, Taiwan, Republic of China. Tel: +886-4-24739595 ext.32346, Fax: +82-, anitayen1971@yahoo.com.tw

• Received: November 24, 2015 • Revised: December 11, 2015 • Accepted: December 12, 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Answer to the Images: Jejunal Lipoma
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Question: A 70-year-old woman presented to our hospital because of a 6-month history of melena. She had had a medical history of chronic hepatitis B and hepatitis C for decades. Moreover, she underwent a laparotomy 20 years previously. Physical examination revealed unremarkable abnormalities. Laboratory tests revealed a hemoglobin level of 9 g/dL. Esophagogastroduodenoscopy, colonoscopy, and small bowel series all failed to detect a bleeding source. Subsequently, spiral enteroscopy was performed perorally by using a specialized overtube (Endo-Ease Discovery Small Bowel; Spirus Medical, Inc., Stoughton, MA, USA) and an enteroscope (Fujinon EN-450T5; Fujinon Corp., Saitama, Japan). A giant subepithelial tumor with superficial ulceration, measuring 3–4 cm in diameter, was identified in the proximal jejunum (Fig. A). Spiral enteroscopy revealed a thickstalk tumor with a "cushion sign" by a grasping forceps (Fig. B). A gastrointestinal stromal tumor was suspected initially; however, the tumor revealed fat content with an attenuation coefficient of −98 Hounsfield units on CT (Fig. C. arrow). We decided to remove it endoscopically to prevent further risk of rebleeding or obstruction and applied an endoloop to ligate the stalk of the tumor (Fig. D). After looping of the tumor, a subtotal polypectomy using an electrosurgical snare was performed (Fig. E). The tumor showed a positive "naked fat sign" on the cutting surface after polypectomy (Fig. F). Pathological evaluation of the resected tumor revealed much adipose tissue with superficial ulceration (Fig. G. H&E, ×40). What is your diagnosis of this subepithelial tumor?

Answer to the Images: Jejunal Lipoma

Small bowel lipomas are rare and often asymptomatic. If symptomatic, they present with abdominal pain, hemorrhage, intestinal obstruction, intussusception, or perforation.1 Lipomas are more common in the ileum than in the duodenum and jejunum.1 These tumors are difficult to diagnose preoperatively. On endoscopic examination, lipomas are characteristically smooth, yellowish, round, or hemispherical tumors with either a pedunculated or wide base. The "cushion sign" and "naked fat sign" are endoscopic characteristics of lipomas. Balloon-assisted enteroscopy is a powerful useful modality for detecting small bowel lipomas.2 Surgical or endoscopic resection is needed for most symptomatic lipomas; however, it is not clear whether asymptomatic lipomas require any intervention.3 Endoscopic resection of lipomas is a challenge for endoscopists because fatty tissue of lipoma is an inefficient conductor of electric current and results in an increased risk of hemorrhage or perforation. Endoloop-assisted polypectomy for lipomas have been reported previously, mostly in the colon and duodenum.4 5 Herein, we report for the first time a case of a large symptomatic jejunal lipoma treated with endoloop-assisted polypectomy using spiral enteroscopy.

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Financial support: None.

Conflict of interest: None.

REFERENCES

1. Wilson JM, Melvin DB, Gray G, Thorbjarnarson B. Benign small bowel tumor. Ann Surg 1975;181:247–250.PMID: 1078626.PubMed PMC
2. Chou JW, Feng CL, Lai HC, et al. Obscure gastrointestinal bleeding caused by small bowel lipoma. Intern Med 2008;47:1601–1603.PMID: 18797119.Article PubMed
3. Yu HG, Ding YM, Tan S, Luo HS, Yu JP. A safe and efficient strategy for endoscopic resection of large, gastrointestinal lipoma. Surg Endosc 2007;21:265–269.PMID: 17122972.Article PubMed PDF
4. Koo J, Kaffes A. Endoscopic resection of large colonic lipomas assisted by a prototype single-use Endoloop device. Endoscopy 2006;38:644–647.PMID: 16802274.Article PubMed PDF
5. Huang WH, Peng CY, Yu CJ, Chou JW, Feng CL. Endoloop-assisted unroofing for the treatment of symptomatic duodenal lipomas. Gastrointest Endosc 2008;68:1234–1236.PMID: 19028236.Article PubMed

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A large symptomatic jejunal subepithelial tumor treated with endoloop-assisted polypectomy using spiral enteroscopy

Intest Res. 2016;14(1):104-105. Published online January 26, 2016

DOI: https://doi.org/10.5217/ir.2016.14.1.104

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A large symptomatic jejunal subepithelial tumor treated with endoloop-assisted polypectomy using spiral enteroscopy