John Robinson Saltzman, MD; David L. Carr-Locke, MD, FRCP; Scott Andrew Fink, MD, MPH

Disclosures

January 18, 2005

Discussion

Gastrointestinal lipomas are typically found in patients who are in their fifth or sixth decade of life.[1,2] Approximately 220 cases of gastric lipomas have been reported in the literature.[2,3,4] Similar in pathologic and gross appearance to lipomas found elsewhere in the gastrointestinal tract, gastric lipomas appear as solitary, smooth, discrete, soft masses. Gastric lipomas appear yellow and adipose when transected.[1] Microscopically, gastric lipomas consist of well-differentiated adipose tissue surrounded by a fibrous capsule.[2] Corresponding with their histologic locations elsewhere and in the gastrointestinal tract, 90% of gastric lipomas are located in the submucosa, with the remainder arising from the subserosa.[1,5,6]

Gastric lipomas > 2.0 cm in size are most likely to cause symptoms that include intussusception, diarrhea, constipation, or gastrointestinal hemorrhage.[1,5,7] Turkington's 1965 review[6] of all 157 cases of gastric lipomas reported in the literature to that point showed that lipomas had been reported as arising from all parts of the stomach except for the cardia and pylorus. Seventy-five percent were located in the antrum. Ulceration with necrosis and inflammation were frequent. Malignant degeneration of a gastric lipoma has not been reported.

Hemorrhage, abdominal pain, obstruction, and dyspepsia represent the most common symptoms associated with gastric lipomas, although the vast majority are thought to be asymptomatic and are discovered incidentally. Lipomas closest to the pylorus can cause obstructive symptoms, frequently by obstructing the pylorus or prolapsing through the pylorus into the duodenum.[6] A more recent case series reported on patients with gastric lipomas, with the most common presenting symptoms being abdominal pain (50%) and gastrointestinal bleeding (37.5%).[1,6] Hemorrhage is thought to occur secondary to the lipoma's contact with the opposing wall, which can result in ulceration and necrosis of central areas.[2]

Endoscopically, gastric lipomas typically appear as smooth submucosal masses with a yellowish hue when compared with surrounding tissue, occasionally with areas of discrete ulceration.[8]Typically, 2 clues help to identify these lesions as lipomas on endoscopic examination. "Tenting" occurs when the normal mucosa overlying the lipoma is retracted easily away from the mass with a biopsy forceps, and the "cushion sign" occurs when the forceps produces a soft, cushioning indentation when applied to the lipoma.[8] Because the lipoma is submucosal, standard biopsies typically are inadequate.[8] Yashida and colleagues[9] have reported using electrocautery to produce a small overlying area of ulceration that can be biopsied to reveal the lipoma on repeat endoscopic examination a few days later. Another diagnostic sign is the "naked fat" sign, which refers to exposed adipose tissue on the surface of the lipoma that pokes through the normal overlying mucosa after multiple biopsies of the normal mucosa are performed.[5] Because computed tomography (CT) findings have demonstrated utility in the diagnosis of gastric lipomas, it has been suggested that CT scanning of large (> 2 cm) submucosal gastric masses detected on endoscopy can obviate the need for biopsy.[2,3,8,10] Endoscopic ultrasound has also been used to help identify gastric lipomas.[11]

Surgical resection remains the treatment of choice for symptomatic lipomas. Although it is only a temporizing measure, hemostasis of the bleeding ulceration from a gastric lipoma through the use of hemostatic endoscopic clips has not been reported previously.

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