Gastric outlet obstruction from duodenal lipoma in an adult

Management of a Rare Challenging Case of Duodenal Ampullary Lipoma

Duodenal lipoma is a very rare entity with limited case reports present in literature. But duodenal ampullary lipomas are even more rare in nature. Owing to the recent advances in endoscopy and modern imaging techniques, more cases are being diagnosed and treated. However, challenge lies in performing a less invasive and least morbid procedures to treat them surgically in such complex location of tumour. To study the diagnosis and treatment of duodenal ampullary lipoma in a young male patient and challenges faced during surgical management. A 15-year-old young boy presented to us with complaints of intermittent upper gastrointestinal bleed and jaundice since last 2 months. At admission, his serum haemoglobin was 3 g% for which he was transfused 3 units of packed blood cells for optimization. On further evaluation, CT scan abdomen revealed 71 × 49 mm large heterogeneous mass in D3 segment of duodenum causing duodeno-duodenal intussusception involving D1 and D2 segment along with ampullary region with mass being the lead point. There was compression of CBD with dilatation measuring 11 mm in diameter and mild IHBR dilatation. UGIE revealed narrowing at D1-D2 junction due to polypoidal lesion with overlying smooth mucosa with no active bleeding point identified. His blood parameters were normal except for low haemoglobin (before blood transfusion) and total serum bilirubin of 2.3 mg/dl.He was optimized for surgery and underwent exploratory laparotomy with duodenotomy at D2 with mass excision of 7 × 5 cm sessile polyp with base over ampulla followed by plastic repair of sphincter of Oddi (pancreas preserving procedure). He was started on oral liquids on POD 3 and was discharged on normal diet by POD 7 with an uneventful recovery. Result of histopathological report revealed, on gross cut section, the presence of mass of 7 × 5 × 3 cm size with smooth mucosa and fibrofatty tissue. On microscopic examination, diagnosis of submucosal lipomatous polyp was made. Our case report indicated duodenal ampullary lipoma is extremely rare entity. The symptoms are nonspecific and CT scan abdomen is the first investigation of choice for diagnosis. The treatment depends on the patient's condition as well as the size and position of the tumour. In our case report, the tumour base was exactly at the level of ampulla where we performed complex procedure of local excision of mass with sphincteroplasty avoiding major Whipple procedure for such benign condition. It provided rapid postoperative recovery to the patient.

Treatment of duodenal lipoma with robotic-assisted transverse duodenotomy: A case report of novel approach

Introduction and importance

Lipomas are the third most common benign tumor of the gastrointestinal (GI) tract, typically occurring in the colon or small intestine. Less than 100 cases of symptomatic duodenal lipomas have been reported. Symptoms include non-specific upper GI complaints of heartburn, fullness, or abdominal pain. This report highlights the rarity of symptomatic duodenal lipomas, lack of specific treatment guidelines, and adds to surgical literature a new treatment approach.

Case presentation

A 53-year-old Caucasian woman presented with 2-year history with main concerns for early satiety and constipation. CT scan with contrast of the abdomen and pelvis demonstrated a duodenal mass. Differential diagnosis included duodenal lipoma versus stricture, and IBS. Subsequent EGD revealed a 4 cm transverse duodenal submucosal mass. Endoscopic removal was deemed too great a risk of bleeding. Pre-operatively, the patient expressed frustration as the patient was tolerating only a liquid diet with one bowel movement weekly. Treatment with robotic assisted transverse duodenotomy was performed, with final pathology of benign lipomatous tissue. Post-operatively the patient had immediate relief of symptoms which persisted at 2-week and 4-month follow-ups.

Clinical discussion

This case demonstrates 3 primary learning points. First, duodenal lipomas should be included in the differential of vague upper GI symptoms. Second, we propose that surgeons consider treatment of duodenal lipomas utilizing robotic assisted approach. Third, we document the first robotic-assisted transverse duodenotomy for duodenal lipomas.

Conclusion

Clinicians should consider duodenal lipoma for patients with vague abdominal symptoms. We present a case of successful treatment with robotic-assisted transverse duodenotomy.

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Only a few cases of symptomatic duodenal lipoma have been reported.

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No specific treatment guidelines exist for duodenal lipomas.

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First-reported treatment of duodenal lipoma via robotic-assisted transverse duodenotomy

Duodenal descending part-jejunum intussusception and upper gastrointestinal bleeding caused by duodenal fibrolipoma: a case report

Background

Duodenal fibrolipoma and duodenum-jejunum intussusception are both rare occasions in clinical practice. The diagnosis of duodenal fibrolipoma mainly depends on endoscopy examination, supplemented by CT and MRI. As the tumor grows, some severe symptoms need surgical intervention. As the development of endoscopic techniques, the operation plan should be made individually.

Case presentation

A 47-year-old female with the complaint of upper abdominal pain and melena was reported. Abdominal examination revealed upper abdomen lightly tender and blood test showed severe anemia. Image and endoscopy examination exhibited “a giant mass” in the descending (D2) part of duodenum, dragged by the tumor into the distal intestinal canal and causing intussusception. Intermittent blood transfusion treatment, enteral and parenteral nutrition were adopted to adjust her general state. Two weeks later, the mass was resected together with the basement intestinal wall via the jejunum incision and then the intussuscepted D2 part was restored. The paraffin pathological diagnosis correlated with the preoperative judgment of fibrolipoma and the patient was discharged healthy on POD 14.

Conclusions

Duodenal fibrolipoma is a rare disease, infrequently causing intussusception and severe upper GIB. Duodenoscopy and endoscopic ultrasound contribute to making an appropriate diagnosis, and for patients with severe symptoms needed surgical intervention, operation plan should be individualized depending on the size and location of the lesion.

Diagnosis and Treatment of Duodenal Lipoma: A Systematic Review and a Case Report

INTRODUCTION

Duodenal lipoma is very rare with limited case reports present in literature. Owing to recent advances in endoscopy and modern imaging techniques, more cases are being diagnosed and treated. However, no systematic study of duodenal lipomas has been reported.

AIM

To study the diagnosis and treatment of duodenal lipoma in a female patient and review the relative literatures to enhance the knowledge of it.

MATERIALS AND METHODS

A literature search for 'duodenal lipoma' was performed on PubMed. Papers published from 1948 to 2016 in the English language were identified. Each article was then read in detail and analysed for clinical data, imaging features, diagnosis and therapy. Also, we hereby present a case of upper gastrointestinal obstruction secondary to multiple duodenal lipomas in a 67-year-old woman. The patient underwent a limited bowel resection with an uneventful recovery.

RESULTS

Literature review demonstrated 59 cases of duodenal lipoma, which indicate that duodenal lipomas are rare to occur but commonly found in the second part. The peak of incidence seems to be around the fifth and seventh decade of life. Duodenal lipomas may present as gastrointestinal bleeding, abdominal pain, obstruction or upper abdominal fullness. CT, MRI, Endoscopic Ultrasound (EUS), endoscopy are highly accurate diagnostic tools. The disease could be managed by endoscopy or surgery.

CONCLUSION

Our review of literature indicated duodenal lipoma is extremely rare. The symptoms are nonspecific and CT is the first choice for diagnosis. The treatment depends on the patient's condition as well as the size and position of the tumour.

Multiple Duodenal Lipomas as a Rare Cause of Upper Gastrointestinal Obstruction: Case Report and Literature Review

Duodenal lipomas are rare benign tumors and pose a diagnostic challenge as their symptoms are non-specific. In this article, we reported a case of duodenal lipoma presenting as upper gastrointestinal obstruction and reviewed the literature on relevant clinical manifestation, diagnosis and treatment. Our review of literature indicated that multiple duodenal lipomas as a cause of upper gastrointestinal obstruction as reported here are extremely rare. The preoperative computed tomography and magnetic resonance imaging are the key to diagnosis, and surgical resection is the most effective means for the management of such duodenal lipomas.