AJR 2005; 184:1163-1171
© American Roentgen Ray Society
Imaging and Findings of Lipomas of the Gastrointestinal Tract
William M. Thompson1,2
1 Department of Radiologic Pathology, Armed Forces Institute of Pathology, 2002,
Washington, DC 20306-6000.
Received June 23, 2004;
accepted after revision September 7, 2004.
The opinions and assertions contained herein are the private views of the
author and are not to be constructed as official or as reflecting the views of
the Department of the Army or Department of Defense.
2 Present address: Department of Radiology, Duke University Medical Center,
Box 3808, Durham, NC 27710. Address correspondence to W. M. Thompson
(thomp132{at}mc.duke.edu).
Introduction
The major points made in prior reports are that intestinal lipomas
are uncommon and slow-growing and can occur anywhere along the gut
[1-7].
They are usually solitary but can be multiple anywhere in the gastrointestinal
tract [7] (Figs.
1A,
1B,
2A,
2B,
3A,
3B,
4,
5A,
5B,
6A,
6B,
7A,
7B,
7C,
8A,
8B,
9A,
9B,
10A,
10B,
10C,
11A,
11B,
12A,
12B,
13A,
13B,
14,
15,
16). Although lipomas are
submucosal tumors, they may appear to be totally intraluminal
[1] (Figs.
5A,
5B,
6A,
6B,
7A,
7B,
7C,
8A and
14). These tumors have the
gross appearance of subcutaneous fat
[1,
2]
(Fig. 13B). Many lipomas are
found incidentally, but they can have a pseudopedicel and cause an
intussusception [4,
5] (Figs.
8A,
8B,
9A,
9B,
15, and
16). When they are larger than
2 cm, they may ulcerate, leading to acute or chronic anemia (Figs.
2A,
2B,
3A, and
3B). Ulceration or vascular
compromise due to an intussusception can cause acute blood loss
[1].
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Fig. 1A. —84-year-old man who presented with minimal dysphagia for many
years and every 2-3 years would regurgitate large fleshy mass that, when
resected, proved to be angiolipoma. This tumor is composed of mature adipose
tissue and blood vessels with fatty tissue predominating. On imaging, this
lesion is indistinguishable from routine lipomas. Right lateral oblique view
from barium swallow shows huge mass extending from above aortic arch
(upper arrow) to lower third of esophagus (lower arrow).
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Fig. 1B. —84-year-old man who presented with minimal dysphagia for many
years and every 2-3 years would regurgitate large fleshy mass that, when
resected, proved to be angiolipoma. This tumor is composed of mature adipose
tissue and blood vessels with fatty tissue predominating. On imaging, this
lesion is indistinguishable from routine lipomas. Gross specimen shows large 6
x 15 cm angiolipoma, which was resected from esophagus.
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Fig. 2A. —66-year-old woman who presented with abdominal pain and
chronic gastrointestinal bleeding due to gastric lipoma. Single
anteroposterior radiograph from upper gastrointestinal examination shows large
4 x 5 cm gastric antral mass (arrows) with central ulceration
(arrowhead).
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Fig. 2B. —66-year-old woman who presented with abdominal pain and
chronic gastrointestinal bleeding due to gastric lipoma. Gross specimen shows
two areas of ulceration (arrows) in antral mass. Note relatively
smooth mucosa over lipoma.
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Fig. 3A. —77-year-old woman with unexplained gastrointestinal bleeding
due to gastric lipoma. (Reprinted from
[3]) Upper gastrointestinal
radiograph shows 5-cm antral mass (arrow) with central ulceration
(arrowhead).
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Fig. 3B. —77-year-old woman with unexplained gastrointestinal bleeding
due to gastric lipoma. (Reprinted from
[3]) Axial CT scan reveals mass
in antrum with fat attenuation. Note central ulceration filled with barium
(arrow). Ulceration was present in gross specimen (not shown).
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Fig. 4. —75-year-old woman with acute onset of gastrointestinal
bleeding due to lipoma. Upper gastrointestinal examination showed large 8-cm
mass with central ulceration (not shown). CT scan obtained through antrum
shows low-density mass (arrow) containing some high-density
stranding. Ulcer is not visible. Higher density is probably due to ulceration.
(Reprinted from [3])
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Fig. 6A. —52-year-old man with chronic upper abdominal pain due to
multiple lipomas. Patient has Proteus syndrome, which is condition involving
atypical growth of bones, skin, and head with tumors of subcutaneous tissue
and lipomas of intestine. Anteroposterior view from upper gastrointestinal and
small-bowel radiograph shows multiple lobulated polypoid masses
(arrow) in duodenal bulb. Small-bowel radiograph (not shown) revealed
many other polypoid filling defects.
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Fig. 6B. —52-year-old man with chronic upper abdominal pain due to
multiple lipomas. Patient has Proteus syndrome, which is condition involving
atypical growth of bones, skin, and head with tumors of subcutaneous tissue
and lipomas of intestine. Axial CT scan shows multilobulated fatty masses in
duodenal bulb (arrow), diagnostic of lipomas. Multiple large and
small hepatic cysts are also shown (arrowheads). CT scans of lower
abdomen (not shown) revealed numerous lipomas in small bowel.
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Fig. 7B. —55-year-old woman with long-standing crampy abdominal pain
due to lipoma producing intussusception. Axial CT scan obtained through lower
abdomen shows small-bowel intussusception (arrow).
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Fig. 7C. —55-year-old woman with long-standing crampy abdominal pain
due to lipoma producing intussusception. Axial CT scan obtained few
centimeters lower than A shows fatty tumor (arrow), which was
lead point for intussusception.
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Fig. 8A. —39-year-old man with crampy mid-epigastric pain increasing
over past 3 months due to ileal lipoma producing intussusception.
Anteroposterior radiograph from small-bowel follow-through shows small
2-cm-in-diameter (arrow) intraluminal mass producing partial
intussusception (arrowheads).
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Fig. 8B. —39-year-old man with crampy mid-epigastric pain increasing
over past 3 months due to ileal lipoma producing intussusception.
Intraoperative photograph shows intussusception. Clamp is holding up
intussusceptum and arrowheads mark intussuscipiens. Lead point, lipoma, is
marked by white arrow. Note mesenteric fat along inferior portion of bowel,
which was responsible for asymmetric low-density crescent seen on CT (also see
Figs. 7A,
7B,
7C,
9A, and
9B).
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Fig. 9A. —44-year-old man with 6 months of periumbilical abdominal pain
after eating, due to lipoma producing an ileal-colonic intussusception.
Anteroposterior radiograph from single-contrast barium enema shows
ileal-colonic intussusception (arrow).
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Fig. 9B. —44-year-old man with 6 months of periumbilical abdominal pain
after eating, due to lipoma producing an ileal-colonic intussusception. Axial
CT scan shows intussusception (arrows) due to lipoma that was present
on lower CT images (not shown). CT slice shows intussusception in oblique
axis, showing both axial and partial longitudinal views. Note asymmetric
crescent of low density due to mesenteric fat of small bowel.
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Fig. 10A. —18-year-old woman with crampy abdominal pain due to lipoma,
which had produced intussusception. Axial CT scan shows complex mass in small
bowel with areas of high and low attenuation (arrows). There is no
obvious fat density.
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Fig. 10B. —18-year-old woman with crampy abdominal pain due to lipoma,
which had produced intussusception. Axial CT scan in lower abdomen shows a
complex mass (arrows) without obvious findings to suggest
intussusception. Note areas of fluid and soft-tissue attenuation. Fatty
attenuation in center of mass (arrowhead) suggests diagnosis of
lipoma.
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Fig. 10C. —18-year-old woman with crampy abdominal pain due to lipoma,
which had produced intussusception. Gross specimen shows lipoma
(arrowhead) and necrotic bowel (arrow) found at surgery due
to complicated intussusception.
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Fig. 11A. —50-year-old man with long history of abdominal pain due to
diffuse small-intestinal lipomatosis and underlying Crohn's disease.
Anteroposterior view from small bowel follow-through shows diffuse submucosal
masses throughout entire small bowel.
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Fig. 11B. —50-year-old man with long history of abdominal pain due to
diffuse small-intestinal lipomatosis and underlying Crohn's disease. Axial CT
scan shows diffuse low-density masses throughout entire small bowel due to
multiple lipomas through mesentery and submucosa of small intestine. At
surgery, patient was found to have Crohn's disease involving distal ileum,
which was not shown on small-bowel follow-through.
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Fig. 12A. —42-year-old woman with 1 week of mid-abdominal and epigastric
pain due to two lipomas producing colocolonic intussusception in cecum and
right colon. Axial CT scan shows complex mass (arrow) involving right
colon without obvious findings to suggest lipoma or intussusception.
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Fig. 12B. —42-year-old woman with 1 week of mid-abdominal and epigastric
pain due to two lipomas producing colocolonic intussusception in cecum and
right colon. Gross specimen shows two intraluminal lipomas measuring 5 and 3.5
cm, with distortion of lipomas due to edema. These findings explain atypical
appearance of intussusception with lead point due to lipomas.
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Fig. 13B. —65-year-old woman with 1 month of abdominal pain due to
lipoma. Gross specimen of colon wall is seen in cross section. Lipoma
(arrow) has been bivalved, and fatty nature of tumor is well shown.
Note that lipoma is intraluminal, projecting above colonic mucosa
(arrowheads).
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Fig. 14. —54-year-old woman with 2 days of bright red blood due to
lipoma in descending colon. Oblique spot radiograph from double-contrast
barium enema shows lobulated polypoid mass (arrow) in descending
colon. Axial CT scan (not shown) showed mass with fat attenuation diagnostic
of lipoma.
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Fig. 15. —24-year-old man with 5 months of intermittent abdominal pain
and 40-lb (18 kg) weight loss due to lipoma, which produced intussusception.
Sonogram of left upper quadrant shows echogenic mass (arrows) within
distal transverse colon. CT scan (not shown) revealed intussusception in
region of splenic flexure with lead point lipoma.
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Fig. 16. —40-year-old man with 1 month of intermittent abdominal cramps
due to lipoma, which produced colocolonic intussusception. Sonogram with
transverse view of left upper quadrant shows echogenic mass, which has
pseudokidney appearance. CT scan (not shown) revealed intussusception due to
lipoma.
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Taylor et al. [1] in 1990
provided a comprehensive review of the findings on barium studies and
endoscopy with a brief discussion of some of the CT findings. Although
uncomplicated gastrointestinal lipomas are easily diagnosed on CT and MRI,
complications such as ulceration and intussusception may obscure the diagnosis
[2,
3,
5]. This pictorial essay
reviews the imaging features of lipomas of the gut with emphasis on
cross-sectional imaging and radiographic-pathologic correlation.
General Comments
On barium contrast studies, the classic lipoma is a smooth, oval, or
spherical mass with very distinct margins and compresses easily on palpation
during fluoroscopy [1] (Figs.
2A,
3A,
5A,
7A, and
8A). Lipomas may be lobulated
and can show ulceration especially when they are larger than 2 cm (Figs.
2A and
3A). Barium contrast
examinations with high kilovoltage may make it difficult to detect the
reported significant low density of lipomas
[1].
On CT, the finding of a homogeneous mass with Hounsfield units between -80
and -120 is virtually diagnostic of a lipoma
[2-4]
(Figs. 3B,
4,
5A,
6A,
7C, and
13A). Heiken et al.
[2] reported that lipomas
virtually never contain nonfatty elements. However, Taylor et al.
[1] reported two gastric
lipomas with linear strands of soft-tissue attenuation at the base of the
lipomas and associated ulceration. The strands or septa on pathologic
evaluation were due to inflammation associated with an ulcer. Thompson et al.
[3] reported a similar case
(Fig. 4).
Intussusception of the small bowel and colon is a common presentation of
lipomas (Figs. 7A,
7B,
7C,
8A,
8B,
9A, and
9B). The low attenuation of
the lipomas can usually be detected on CT, but as Buetow et al.
[5] reported in their series of
10 colonic intussuscepted lipomas, nine showed some loss of fat density with
one showing entirely soft-tissue attenuation (Figs.
12A, and
12B). In these cases, the
colonic mass may have the appearance of a malignancy. Small intestinal lipomas
with a complicated intussusception may not have the classic CT characteristics
(Figs. 10A,
10B, and
10C).
On sonography, lipomas are echogenic (Figs.
15 and
16). If there is an
intussusception present, sonography can show the classic doughnut,
"pseudokidney," or target sign
[8] (Figs.
15 and
16).
Individual Sites
Esophagus
Lipomas of the esophagus are less common than leiomyomas and fibrovascular
polyps [7]. They usually are
found in the upper one third of the esophagus, but they can occur anywhere in
the pharynx and esophagus [7]
(Figs. 1A, and
1B). Although they may be very
large, esophageal lipomas may not produce symptoms because they rarely cause
obstruction or ulceration (Figs.
1A, and
1B).
Stomach
The stomach is the third most common site for gastrointestinal lipomas, but
only about 5% occur here. They most commonly occur in the antrum (Figs.
2A,
2B,
3A,
3B,
4), and therefore if they are
pedunculated, they can prolapse into the pylorus. They are soft and thus do
not produce gastric outlet obstruction. Ulceration is common when gastric
lipomas are larger than 2 cm
[3] (Figs.
2A,
2B,
3A, and
3B).
Duodenum
Duodenal lipomas are usually solitary and can occur anywhere in the
duodenum, including the bulb (Figs.
5A, and
5B). They are rarely multiple
(Figs. 6A, and
6B).
Small Bowel
Approximately 20-25% of gastrointestinal lipomas occur in the small-bowel,
which is the second most common site for lipomas of the gut
[1]. They are the second most
common benign small-bowel tumor after gastrointestinal stromal tumors
[1]. They are usually solitary
(Figs. 7A,
7B,
7C,
8A,
8B,
9A,
9B,
10A,
10B, and
10C) but can be multiple, and
when they are multiple and subserosal, they can be seen in association with
Crohn's disease (Figs. 11A,
and 11B). The ileum is the
most common site (Figs. 7A,
7B,
7C,
9A,
9B,
10A,
10B, and
10C), but gastrointestinal
lipomas can occur more proximally (Figs.
8A, and
8B).
Colon
Approximately 65-75% of bowel lipomas are located in the colon, the most
common site. They are the second most common benign lesion in the colon but
are far less common than adenomatous polyps
[2,
4]. The cecum (Figs.
12A, and
12B) is the most common
location, followed by the right colon (Figs.
13A, and
13B), and then the sigmoid.
Colonic lipomas are usually solitary (Figs.
13A,
13B,
14,
15,
16), but they can be multiple
(Figs. 12A, and
12B). True lipomas of the
ileocecal valve should not be confused with lipomatosis of the valve, which is
much more frequent. A true lipoma will produce an asymmetric mass, whereas the
latter has symmetric enlargement of the valve.
Acknowledgments
Most of the material presented in this report was collected at the Armed
Forces Institute of Pathology after institutional review board approval. I
thank Angela D. Levy of the Department of Radiologic Pathology, Washington,
DC, for her assistance in providing the case material for this work.
References
- Taylor AJ, Stewart ET, Dodds WJ. Gastrointestinal lipomas: a
radiologic and pathologic review. AJR1990; 155:1205
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- Heiken JP, Forde KA, Gold RP. Computed tomography as a definitive
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Watanabe K. CT manifestations of lipomas of the small intestine and colon.
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Introduction
General Comments
