lipomas are the most common benign mesenchymal tumors of the gastrointestinal tract , with the colon being the most prevalent site .
tumors > 2 cm in diameter may occasionally cause nonspecific symptoms , including change in bowel habits , abdominal pain , or rectal bleeding , but with resection the prognosis is excellent .
herein , we describe the case of an elderly male who presented with painless hematochezia .
both colonoscopy and computed tomography of the abdomen and pelvis confirmed the presence of a mass near the ileocecal valve . because of continuing bleeding , the patient required laparoscopic - assisted right hemicolectomy to resect the mass .
previous cases of ileocecal valve lipomas have been reported in the english literature , with the majority presenting as intussusception or volvulus .
we present a rare case of an ulcerated ileocecal valve lipoma presenting as lower gastrointestinal bleeding that was treated successfully with laparoscopic resection .
distribution of alimentary lipomas demonstrates a predilection for the colon , but they may originate anywhere in the gastrointestinal tract , from the hypopharynx to the rectum . often asymptomatic and detected incidentally at the time of colonoscopy or surgery , lipomas
> 2 cm in diameter may occasionally cause nonspecific symptoms , including change in bowel habits , abdominal pain , or rectal bleeding .
diagnosis of gastrointestinal lipomas may involve barium enema , colonoscopy , or computed tomography ( ct ) .
diagnosis is notoriously difficult given that malignant disease can not be excluded definitively through imaging or biopsy alone . a wide range of operative and nonoperative techniques has been utilized for resection .
few cases of lipoma have been reported to date with origin at the ileocecal valve , the majority of which have presented as intussusception or volvulus .
we describe a rare case of an ulcerated ileocecal valve lipoma associated with lower gastrointestinal bleeding that was significant enough to require urgent laparoscopic resection .
a 77-year - old male with a history of diabetes mellitus , hypertension , coronary artery disease , aortic valve replacement , and coronary artery bypass grafting , who was therapeutic on warfarin , presented to his gastroenterologist with 2 days of painless hematochezia .
outpatient colonoscopy performed at that time revealed a 6-cm cecal mass with mucosal necrosis at the ileocecal valve , as well as a small ulcer at the hepatic flexure . given the colonoscopic findings , the patient was transported urgently to our emergency department . upon presentation ,
the patient was in no acute distress with a core temperature of 36.4c , heart rate of 73 beats/ min , blood pressure of 135/91 mm hg , and respiratory rate of 18 breaths / minute .
his abdomen was soft , nontender , and nondistended with no evidence of peritoneal irritation .
computed tomography of the abdomen and pelvis with oral and intravenous contrast revealed a 1.9-cm x 1.5-cm lesion within the cecum ( figure 1 ) .
the patient was admitted for hemodynamic monitoring , transfusion , and surgical resection of the ileocecal mass .
ct image of mass preoperatively , demonstrating a 1.9-cm  1.5-cm lesion within the cecum ( arrow ) , measuring -80 hounsfield units , consistent with adipose tissue .
the patient received vitamin k and 2 units of fresh frozen plasma for reversal of the effect of warfarin .
nonetheless , hematochezia continued with a steady decrease in hematocrit from 43% to 39% over a 24-hour period . on hospital day 2 , he underwent an uncomplicated laparoscopic - assisted right hemicolectomy and ileo - transverse colostomy .
pathology revealed a 3.5-cm x 2.0-cm x 1.5-cm mass at the ileocecal valve ( figure 2 ) .
the yellow , homogeneous cut surfaces and the microscopic evaluation ( figure 3 ) were both consistent with lipoma of the ileocecal valve .
the patient regained bowel function by postoperative day 4 and was discharged the following day .
intraoperative photograph with cecum opened to reveal a 3.5-cm  2.0-cm  1.5-cm tumor ( bottom arrow ) and ileocecal valve ( top arrow ) .
histopathology of lipoma : hematoxylin and eosin stain ( 20 magnification ) reveals a circumscribed collection of mature adipocytes .
gastrointestinal lipomas are benign lesions arising from the adipocytes within the intestinal submucosa with the first case reported by bauer in 1757 . with a reported incidence of 0.2% to 4.4% , lipomas are the third most common benign colonic neoplasm following hyperplastic and adenomatous polyps .
lipomas are found most commonly in the colon , with the highest frequency found in the ascending colon and cecum followed by the transverse colon , descending colon , sigmoid , and least often the rectum . despite the propensity for colonic distribution , lipomas can occur anywhere along the alimentary tract , including the hypopharynx , stomach , small bowel , and esophagus . when confined to the colon , 90% of these lesions
are localized to the submucosa ; however , a few reports have suggested an origin in the subserosal plane .
these tumors are more prevalent in women and are typically discovered during the fifth or sixth decade of life .
they vary in size and can be sessile or pedunculated . cases of multiple lesions have been reported .
lipomas are generally asymptomatic and are identified most commonly as incidental findings during colonoscopy , surgery , or autopsy . in the minority of patients who do present with symptoms , the lesions tend to be > 2 cm in diameter , as in the present case .
common symptoms include constipation , diarrhea , colicky abdominal pain , or lower gastrointestinal bleeding .
abdominal pain may be associated with intermittent intussusception , whereas gastrointestinal bleeding is secondary to ulceration of the overlying mucosa . in rare cases
, patients can present with dramatic clinical symptomatology that requires urgent operative intervention , usually for intussusception or acute hemorrhage . our patient presented with hematochezia
likely secondary to the combination of the size , mucosal necrosis at the surface of the lipoma , and the patient 's anticoagulation regimen .
a variety of imaging modalities are available to assist in the preoperative diagnosis of gastrointestinal lipoma .
barium enema shows colonic lipomas as ovoid , well - delineated , and smooth radiolucent masses . a  squeeze sign 
can also be noted , which indicates a change in size and shape of the lesion due to peristalsis .
computed tomography scanning is a second modality that provides a more definitive diagnosis in uncomplicated cases , where lipomas appear as sharply demarcated ovoid lesions with absorption densities of -40 to -120 hounsfield units . in the present case ,
lastly , endoscopy is a third diagnostic tool with 2 typical findings :  tenting  is described when the mucosa overlying the lipoma is easily retracted away from the mass with biopsy forceps , and a  cushion sign  is present when the forceps produces a soft , cushioning indentation when applied to the lipoma . due to the submucosal location of these lipomas ,
rarely , colonoscopy can reveal ulcerations and a lack of the  cushion sign ,  which may lead to the impression of malignant disease as in the case of our patient .
katsinelos et al described 11 lesions that demonstrated malignant features on colonoscopy but were proved ultimately to be benign lipomas on histopathology examination .
preoperative diagnosis of gastrointestinal lipomas can be difficult when it presents as signs and symptoms suggesting malignant disease that can not be excluded definitively through imaging or biopsy alone .
the greatest clinical importance of intestinal lipoma is its potential to be confused with malignant colonic neoplasm .
immediate surgical intervention is mandatory in cases of obstruction , intussusception , perforation , or massive hemorrhage with the last sign being seen in our patient .
several operative and nonoperative techniques have been described , including laparotomy , mini - laparotomy , and laparoscopy to perform enucleation , colostomy , excision , or segmental colonic resection of lipomas . among the nonoperative techniques ,
endoscopic removal of symptomatic lipomas is controversial due to the inefficient conduction of electric current through adipose tissue .
this inefficiency results in an unacceptably high rate of complications , including perforation or hemorrhage .
previous case reports have demonstrated that ileocecal valve lipomas present most commonly as intussusception or volvulus .
only one of these earlier cases was managed by laparoscopic resection . to our knowledge , laparoscopic
resection has not been utilized in the setting of acute hemorrhage secondary to an ileocecal valve lipoma .
however , given that lipomas disbursed throughout other regions of the large intestine have been resected successfully through laparoscopy , laparoscopic resection may now be considered an excellent , minimally invasive option for the treatment of ileocecal valve lipomas presenting as intussusception , volvulus , or hemorrhage .
we present a case of ileocecal valve lipoma in a patient who presented with acute gastrointestinal hemorrhage .
after an extensive literature review , it was found that the majority of intestinal lipomas present as colonic lipomas with either intussusceptive or obstructive symptoms .
we believe this is a very rare case of an ileocecal valve lipoma presenting as ulcerations and necrosis leading to acute hemorrhage and urgent resection .
 background : lipomas are the most common benign mesenchymal tumors of the gastrointestinal tract , with the colon being the most prevalent site . 
 intestinal lipomas are usually asymptomatic . 
 tumors > 2 cm in diameter may occasionally cause nonspecific symptoms , including change in bowel habits , abdominal pain , or rectal bleeding , but with resection the prognosis is excellent . 
 herein , we describe the case of an elderly male who presented with painless hematochezia.methods:both colonoscopy and computed tomography of the abdomen and pelvis confirmed the presence of a mass near the ileocecal valve . because of continuing bleeding , the patient required laparoscopic - assisted right hemicolectomy to resect the mass.results:both gross and microscopic pathology were consistent with lipoma at the ileocecal valve.conclusion:previous cases of ileocecal valve lipomas 
 have been reported in the english literature , with the majority presenting as intussusception or volvulus . 
 we present a rare case of an ulcerated ileocecal valve lipoma presenting as lower gastrointestinal bleeding that was treated successfully with laparoscopic resection . 