Melissa Vitolo, MD, Robert Coben, MD
Thomas Jefferson University Hospital, Philadelphia, PA
Introduction: GI bleeding remains one of the most common reasons for GI consultation, with top causes including peptic ulcer disease, erosive disease, angiodysplastic lesions, varices, Mallory Weiss tears, dieulafoy lesions, and malignancy. Obscure GI bleeding (OGIB), defined as recurrent or persistent bleeding or anemia despite negative endoscopic evaluation, makes up 5% of all GI bleed cases. Approximately 75% of OGIB are found to have small bowel lesions. We outline a case of a rare cause of OGIB.
Case Description/Methods: A 78-year-old female with history of HTN, HLD, CAD, STEMI s/p DES placement, biliary colic s/p cholecystectomy, is referred to GI clinic for symptomatic anemia. She was found to have a hemoglobin of 8 g/dL from baseline 11-12 g/dL. She had been on dual antiplatelet therapy with ticagrelor until 3 months ago, now on aspirin 81mg. Anemia workup revealed iron deficiency. CT scan negative. Started on po iron with improvement in symptoms. Denied abdominal pain, weight loss, or overt bleeding. No NSAID use. No prior endoscopy or colonoscopy. No family history of GI malignancy.
An upper endoscopy and colonoscopy were done. There was antral erythema, otherwise normal EGD. Duodenal and gastric biopsies were negative. Colonoscopy only notable for extensive diverticulosis and a small tubular adenoma. Capsule endoscopy identified active bleeding in the proximal small bowel and a potential submucosal mass.
Push enteroscopy revealed a long polypoid lesion extending from the third to fourth portion of the duodenum, approximately 15mm in width and at least 100mm in length with visible ulcerated tip. Mucosa was otherwise normal. Endoloop was applied and tissue removed with a hot snare. Pathology resulted in a submucosal lipoma.
She was followed with serial blood counts and continued on iron therapy. She is doing well with continued GI follow up.
Discussion: This case of an ulcerated lipoma as the cause of an OGIB is among a handful of other case reports and seem to be similarly found in patients on antiplatelet or anticoagulation therapy. Other cases have undergone surgical resection for symptomatic lipomas, however our case suggests that perhaps in those that are able to stop antiplatelet therapy and have a lesion within reach of an enteroscope, resection of the ulcerated portion may be sufficient treatment and may avoid invasive surgery.
References: Yatagai, et al. Obscure gastrointestinal bleeding caused by small intestinal lipoma: a case report. J Med Case Rep. 2016;10(1):226. Published 2016 Aug 12.
Citation: Melissa Vitolo, MD, Robert Coben, MD. P0451 - AN ULCERATED LIPOMA AS THE CAUSE OF OBSCURE GASTROINTESTINAL BLEEDING. Program No. P0451. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.