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Image of the Month—Diagnosis FREE

Arch Surg. 2006;141(8):834. doi:10.1001/archsurg.141.8.834.
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ANSWER: INTUSSUSCEPTION CAUSED BY LIPOMA OF THE COLON

Although lipomas of the colon are considered the second most common benign nonepithelial tumors of the colon and rectum,18 they are rare. From July 17, 1997, until October 2004, we encountered 7 cases of lipomas of the colon. The patients ranged in age from 51 to 64 years (median age, 60 years) and included 3 men and 4 women. Their clinical presentation included rectal bleeding (n = 2), pain in the right iliac fossa (n = 3), pain in the left iliac fossa (n = 1), diffuse upper abdominal pain (n = 1), and symptoms and signs of intestinal obstruction (n = 1). Their diagnosis involved flexible sigmoidoscopy, colonoscopy, barium enema, computed tomography, and magnetic resonance imaging. Their management involved right hemicolectomy (n = 1), left hemicolectomy (n = 2), local excision (n = 2), and observation (n = 1).

In general, colonic lipomas are more common in women than men5,8 and occur most often in the fifth and sixth decades of life.5 The incidence is estimated from 0.035% to as high as 4.4% in some series.5 Most lipomas are silent8,9 and often detected incidentally by colonoscopy9 or barium enema.4 The patients may have intussusceptions2,3,5,6 as demonstrated by magnetic resonance imaging, change in bowel habits,5,6 or simple mechanical obstruction.5 Barium enemas are not diagnostic and can miss lipomas smaller than 2 cm8; however, they are mandatory to rule out malignant lesions. On barium study, lipomas are typically round or ovoid, sharply defined, smooth, filling defects.4 Colonoscopy, on the other hand, can readily show lipomas since most of them are submucosal.9 The lipomas typically appear as smooth, spherical, slightly yellowish polyps of variable size9 (0.5 to >5 cm) with either a broad base of attachment or a thick pedicle.9 The mucosa is usually normal; however, it may ulcerate.2,9 Probing the polyp will give you the cushion sign3,9 (pillow-like indentation), and grasping the overlying mucosa with biopsy forceps gives the tenting effect.9 Biopsy may result in an extrusion of yellow fat, the “naked fat” sign.3,9 If a lipoma is removed, it will float in formalin fixative.9 Computed tomography can be used to identify lipomas of the colon easily by their homogeneity,3,4 and it can be used to easily differentiate between liposarcomas by showing absence of heterogeneity and areas of increased density.4 Liposarcomas of the colon are, however, extremely rare.8 Recently, computed tomography colonographic examination (virtual colonoscopy) has been performed to detect colonic lipomas.3

Seventy percent of colonic lipomas are localized in the right colon,3,57 followed by localization in the transverse colon and then the descending colon, an opposite distribution in comparison with adenocarcinoma and adenomatous polyps.7 Colonic lipomas are usually encapsulated submucosally4,6,9 or are occasionally subserosal, and they can also be found in the ileum, duodenum, and jejunum (in decreasing order of frequency).1 There are variable reports of incidents of multiple lipomas in the colon, the highest incidence being 7 of 20 cases.5

Perhaps the greatest clinical significance of lipomas lies in confusing them with adenomatous polyps or other serious pathological abnormalities.9 Theoretically, lipomas should be removed only if they cause symptoms8; however, there is no sure method short of excision for confirming the diagnosis.

The surgical management of lipomas is in the form of colotomy and enucleation or excision.8 Resection, however, is indicated in the presence of intussusception.8 Snaring of lipomas with a 1.5- to 3.0-cm diameter has been advised by Papp and Haubrich.10 On the other hand, Bar-Meir et al11 described safe endoscopic removal of large 5-cm lipomas. The risk of perforation rises with broad-based polyps, and in a recent series,3 a 43% perforation rate was found. Surgical removal, preferably laparoscopically, has been advocated for lipomas larger than 2 cm in diameter.7 Endoscopic removal of small lipomas is generally safe but rarely indicated.5,9

Correspondence: Nasser M. Amer, FRCS, 6 Windmill Close, Upminster, Essex RM14 2HD, England (nasser.amer@btinternet.com).

Accepted for Publication: June 13, 2005.

Megibow  AJRedmond  PEBosniak  MAHorowitz  L Diagnosis of gastrointestinal lipomas by CT. AJR Am J Roentgenol 1979;133743- 745
PubMed Link to Article
Buetow  PCBuck  JLCarr  NJPantongrag-Brown  LRos  PRCruess  DF Intussuscepted colonic lipomas: loss of fat attenuation on CT with pathologic correlation in 10 cases. Abdom Imaging 1996;21153- 156
PubMed Link to Article
Chiba  TSuzuki  SSato  M  et al.  A case of a lipoma in the colon complicated by intussusception. Eur J Gastroenterol Hepatol 2002;14701- 702
PubMed Link to Article
Kakitsubata  YKakitsubata  SNagatomo  HMitsuo  HYamada  HWatanabe  K CT manifestations of lipomas of the small intestine and colon. Clin Imaging 1993;17179- 182
PubMed Link to Article
Haller  JDRoberts  TW Lipomas of the colon: a clinicopathologic study of 20 cases. Surgery 1964;55773- 781
PubMed
Younathan  CMRos  PRBurton  SS MR imaging of colonic lipoma. J Comput Assist Tomogr 1991;15492- 494
PubMed Link to Article
Cossavella  DClerico  GRosato  L  et al.  Lipoma of the colon as an unusual cause of recurring partial intestinal occlusion: clinical case and review of the literature [in Italian]. Minerva Chir 1998;53277- 280
PubMed
Castro  EBStearns  MW Lipoma of the large intestine: a review of 45 cases. Dis Colon Rectum 1972;15441- 444
PubMed Link to Article
Pfeil  SAWeaver  MGAbdul-Karim  FWYang  P Colonic lipomas: outcome of endoscopic removal. Gastrointest Endosc 1990;36435- 438
PubMed Link to Article
Papp  JPHaubrich  WS Endoscopic removal of colonic lipomas. Gastrointest Endosc 1973;2066- 67
PubMed Link to Article
Bar-Meir  SHalla  ABaratz  M Endoscopic removal of colonic lipoma. Endoscopy 1981;13135- 136
PubMed Link to Article

Figures

Tables

References

Megibow  AJRedmond  PEBosniak  MAHorowitz  L Diagnosis of gastrointestinal lipomas by CT. AJR Am J Roentgenol 1979;133743- 745
PubMed Link to Article
Buetow  PCBuck  JLCarr  NJPantongrag-Brown  LRos  PRCruess  DF Intussuscepted colonic lipomas: loss of fat attenuation on CT with pathologic correlation in 10 cases. Abdom Imaging 1996;21153- 156
PubMed Link to Article
Chiba  TSuzuki  SSato  M  et al.  A case of a lipoma in the colon complicated by intussusception. Eur J Gastroenterol Hepatol 2002;14701- 702
PubMed Link to Article
Kakitsubata  YKakitsubata  SNagatomo  HMitsuo  HYamada  HWatanabe  K CT manifestations of lipomas of the small intestine and colon. Clin Imaging 1993;17179- 182
PubMed Link to Article
Haller  JDRoberts  TW Lipomas of the colon: a clinicopathologic study of 20 cases. Surgery 1964;55773- 781
PubMed
Younathan  CMRos  PRBurton  SS MR imaging of colonic lipoma. J Comput Assist Tomogr 1991;15492- 494
PubMed Link to Article
Cossavella  DClerico  GRosato  L  et al.  Lipoma of the colon as an unusual cause of recurring partial intestinal occlusion: clinical case and review of the literature [in Italian]. Minerva Chir 1998;53277- 280
PubMed
Castro  EBStearns  MW Lipoma of the large intestine: a review of 45 cases. Dis Colon Rectum 1972;15441- 444
PubMed Link to Article
Pfeil  SAWeaver  MGAbdul-Karim  FWYang  P Colonic lipomas: outcome of endoscopic removal. Gastrointest Endosc 1990;36435- 438
PubMed Link to Article
Papp  JPHaubrich  WS Endoscopic removal of colonic lipomas. Gastrointest Endosc 1973;2066- 67
PubMed Link to Article
Bar-Meir  SHalla  ABaratz  M Endoscopic removal of colonic lipoma. Endoscopy 1981;13135- 136
PubMed Link to Article

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