Journal of Surgical Oncology 25133-135 (1984)

Symptomatic Lipoma of the Duodenum

DEBA P. SARMA, MD, THOMAS G. WEILBAECHER, MD, ADlDRAVlD BASAVARAJ, MD, AND

RO RlSA REINA, MD

From the Department of Pathology, Gastroenterology, and Radiology, VA Medical Center and the Louisiana State University Medical School, New Orleans, Louisiana

A case of duodenal lipoma causing massive hemorrhage is described. Literature on the subject is reviewed.

KEY WORDS: lipoma of the duodenum, benign tumor of the duodenum, symptomatic duodenal lipoma, rare tumor of duodenum

INTRODUCTION Lipoma of the duodenum is rare. Weinberg and Feld-

man [1955] could find only 20 examples of submucous duodenal lipomas up to 1948, to which they added 6 cases. Most of these tumors were found incidentally at autopsy and were asymptomatic. Mayo et al [ 19631 stud- ied 160 cases of gastrointestinal lipoma recorded in the surgical pathology section of the Mayo Clinic over a 27- year period and found only six cases of duodenal lipoma.

We want to report a symptomatic case of duodenal lipoma and to analyze six other such cases reported in the English literature.

CASE REPORT A 63-year-old white man came to the hospital with a

4-week history of weakness and episodic passage of tarry stools. There was no history of peptic ulcer disease. He denied any other gastrointestinal symptoms such as pain, cramps, or altered bowel habits.

Physical examination was essentially unremarkable ex- cept for very pale skin and mucous membranes. There was no palpable abdominal mass. Stool was positive for occult blood. Examination of blood revealed a markedly low hemoglobin level of 4.3 gm/dl.

The patient received a total of 8 units of blood and underwent an endoscopic evaluation that revealed a bleeding polypoid mass in the second part of the duo- denum. Multiple biopsies of the lesion were nondiagnos- tic for tumor. An upper gastrointestinal roentgenologic study revealed the mass as a 3-cm filling defect in the second part of the duodenum (Fig. 1).

Accepted for publication June 15, 1983. Address reprint requests to D. Sarma, MD, 1601 Perdido Street, New Orleans, LA 70146.

0 1984 Alan R. Liss, Inc.

Fig. 1 . Second part of the duodenum shows a filling defect caused by the lipoma.

l34 Sarmaetal

TABLE I. Symptomatic Duodenal Lipomas

Authorslyear Clinical features Pathologic features Treatment

Allison et al, 1948

Fawcett et al, I949

Smith et al, 1950

Kirkland et al, I95 I

Duthie et al, 1957

Lemer, 1971

Sarma et al, 1983 (present case)

Man, aged 70. Intermittent melena, 2

yr. X-ray studies, mass in the third part of duodenum.

Man, aged 36. Episodes of melena and

severe fatigue, 2 yr. Episodes of vague abdominal discomfort and nausea, 4 yr. X- ray studies, gastric and duodenal masses.

Man, aged 5 5 . Epigastric pain after

eating, I yr. X-ray studies, healed ulcer and polyoid mass in the first part of duodenum.

Woman, aged 60. Vague gastrointestinal

complaints ever since an attack of jaundice 40 yr previously. X- ray studies, second part of duodenum showed several polypoid masses.

Woman, aged 68. Intermittent attacks of

abdominal colic for 2 yr. Tiredness and weight loss for 6 mo. X-ray studies, tilling defect in the second part of duodenum.

Man. aged 63. Weakness and melena, 3

days. Episodic epigastric pain, 2 yr. X-ray studies, filling defect in the second part of duodenum.

Man, aged 63. Weakness and melena, 4

wk. X-ray studies, filling defect in the second part of duodenum.

Polypoid submucosal lipoma, 5 x 3.5 cm

One 4 x 3.5 cm nonpedunculated and another 7 x 3 cm pedunculated lipomas in the second part of the duodenum. Also a submucosal gastric lipoma.

Pedunculated submucous lipoma, I cm in diameter.

Three sessile submucosal lipomas, the largest measuring 7 x 5 cm in the second part of the duodenum.

Polypoid lipoma, 5 x 3 cm in the second part of the duodenum, attached to the wall by a 2 cm diameter pedicle.

A 4 X 3 cm pedunculated lipoma attached to the first part of duodenum.

A 3-cm submucosal polypoid lipoma attached to the second part of duodenum.

Duodenotomy with excision of the tumor. Symptom-free during the follow-up period of several months.

Partial duodenectomy leading to uneventful recovery.

Excision of the lesion. Uneventful recovery.

Duodenotomy with partial excision of the lipomas. Uneventful recovery.

Biopsy of the mass followed by gastrojejunostomy . Expired on 3rd postoperative day due to coronary occlusion.

Excision of the tumor with the adjacent part of duodenal wall. Uneventful recovery.

Duodenotomy with excision of the tumor. Uneventful recovery.

Symptomatic Lipoma of the Duodenum 135

Fig. 2. Low power view of the duodenal lipoma (hematoxylineoxin x 6).

The patient underwent an abdominal exploration and a duodenotomy. The polypoid mass in the second part of the duodenum was excised without any difficulty. The 3- cm polypoid mass was a submucosal lipoma composed of mature lobules of adipose tissue sharply demarcated from the overlying intact mucosa (Fig. 2). The patient made an uneventful postoperative recovery.

DISCUSSION Table I summarizes the essential features of sympto-

matic duodenal lipomas in six cases found in the English literature and the present case. Most of the cases occur in men above 50 yr of age. Youngest patient was a man aged 36 yr. Most common clinical feature appears to be episodes of melena and weakness. Other features include vague abdominal pain or colic and nausea. X-ray studies usually show a filling defect in the duodenum. Most of the cases show a single polypoid submucosal lipoma varying in size from 1 to 7 cm in greatest dimension. Multiple lipomas were seen in two cases, one with three sessile lesions. In about half of the cases the polyp was located in the second part of the duodenum. Duodenot-

omy with an excision of the lipoma at the pedicle or with partial excision of the duodenum is curative in most of the cases.

ACKNOWLEDGMENTS The authors thank Karen Dunn for excellent secretarial

help.

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Mayo CW, Pagtalunan RIG, Brown DJ: Liporna of the alimentary

Smith FR, Mayo CW: Submucous lipomas of the small intestine. Am

Weinberg T, Feldman M: Lipomas of the gastrointestinal tract. Am J

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