Endoscopic diagnosis and treatment of a giant duodenal lipoma presenting with gastrointestinal bleeding.

A 66-year-old man presented with fatigue and acute upper gastrointestinal bleeding (hemoglobin 92g/L). He had melena but no signs of hematemesis. Upper gastrointestinal endoscopy revealed a 35×15-mm large polypoid lesion with multiple ulcerations in the second part of the duodenum (●" Fig.1). No biopsy samples were taken due to the risk of bleeding. The diagnosis was unclear and the patient underwent endoscopic ultrasound, which demonstrated a hyperechoic lesion measuring 11×19mm in diameter in the submucosa in the duodenal wall with intact muscularis propria (●" Fig.2), suggestive of a lipoma. A subsequent capsule endoscopy excluded distal causes of bleeding in the small intestine. Next, the lesion was removed endoscopically using an endoloop and snare without any complication (●" Fig.3). The resected lesion exhibited multiple ulcerated areas (●" Fig.4). Histological examination demonstrated a duodenal lipoma with large blood vessels in contact with these ulcerated areas (●" Fig.5). Duodenal lipomas are extremely rare and constitute only one in 600 benign tumors of the gastrointestinal tract [1]. Duodenal lipomas are usually asymptomatic but larger ones can, in rare cases, cause abdominal pain, intestinal obstruction, or hemorrhage [2,3]. Symptomatic duodenal lipomas should be removed. The current recommendation is endoscopic excision, unless this is technically difficult and warrants surgical excision. Nonetheless, this unusual case with a duodenal lipoma causing upper gastrointestinal bleeding underlines the clinical importance of endoscopic ultrasound in the workup of patients with unclear submucosal lesions in the gastrointestinal tract. Endoscopy_UCTN_Code_CCL_1AB_2AZ