Large bleeding duodenal lipoma.

Competing Interests: Disclosure All authors disclosed no financial relationships. Commentary Although subepithelial lipomatous lesions of the GI tract remain largely asymptomatic and are incidentally found during endoscopy, these lesions may lead to bowel obstruction and GI bleeding if larger than 2 centimeters. Historically, a surgical approach has been the first treatment modality because of high concern for bleeding and perforation associated with endoscopic resection. Advances in endoscopic resection techniques such as EMR and endoscopic submucosal dissection (ESD) have enabled safe resection of these lesions. The wide-base stalks of pedunculated lipomatous lesions contain the major feeding vessel; thus, preventative coagulation and tamponade of the vessel would facilitate endoscopic resection and minimize the risk of postpolypectomy bleeding. This can be achieved by placement of either a detachable snare or a hemostatic clip to “strangulate” the stalk. Blanching of the polyp is a clue for optimal placement of the detachable snare or clips at the base of the stalk. Bleeding prevention can be reinforced with epinephrine injection at the base of the lipoma. The only caveat with removing such large lesions by EMR is uncertainty with regard to en bloc resection arising from an often challenging position and limited visualization. By contrast, ESD ensures dissection of the lesion from the stalk within the submucosa, the surface capsule being kept intact. It is worth noting that the majority of lipomatous lesions are benign lipomas, but rarely liposarcoma or pleomorphic lipoma/liposarcoma can be seen. It has been hypothesized that a larger size of the subepithelial fat could lead to superficial pressure necrosis of the mucosal surface and result in ulceration and bleeding. As demonstrated in these cases, the superficial mucosa is grossly intact except areas with small ulcerations and erosions, usually towards the tip of the lesion or at the point affected the most by the bowel peristalsis. Tara Keihanian, MD, MPH, Assistant Professor, Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, USA Amy Tyberg, MD, FASGE, FACG, Associate Editor for Focal Points