Endoscopic Treatment of a Symptomatic Ileal Lipoma with Recurrent Ileocolic Intussusceptions by Using Cap-Assisted Colonoscopy
A 73-year-old woman presented with intermittent abdominal pain and weight loss of 15 kg for the past 2 years. Her pain was frequently accompanied by nausea and/or diarrhea and tended to be aggravated by food intake. Her past medical and familial histories were unremarkable. On examination, vital signs were stable but she appeared a little chronically ill. Her abdomen was soft with no palpable mass; bowel sounds were somewhat increased and mild tenderness was noted in the right lower quadrant (RLQ). Initial laboratory blood tests were normal.\nColonoscopy revealed an erythematous polypoid mass at the proximal ascending colon and it seemed to have a huge stalk thicker than the mass itself (). With air being inflated during colonoscopy, it was not seen in the colonic lumen and abruptly disappeared. As the endoscope was advanced through the ICV, there was a polypoid mass in the terminal ileum and multiple tiny hemorrhagic spots on the ileal mucosa; the mass intussuscepted into the colon through the ICV had reverted back to its original site in the terminal ileum (). The thick stalk must have been an intussusceptum of the terminal ileum with the mass as a lead point. In its original position in the ileum, a short stalk was identified on the base of the polypoid mass. Additionally, abdominal computed tomography (CT) scan revealed a well-demarcated pedunculated subepithelial mass with fat attenuation indicating a lipoma of the terminal ileum ().\nThis ileal lipoma was thought to have been responsible for her abdominal pain and weight loss on account of repeated ileocolic intussusceptions causing intermittent intestinal obstructions. Because the patient strongly refused surgical treatment, we planned to endoscopically remove her ileal lipoma considering potential sequelae of ileal resection. In order to perform endoscopic procedure in the spacious colonic lumen, we tried to retract the mass into the colonic lumen through the ICV but unfortunately failed. Therefore, to keep a clear visual field within the narrow lumen of the ileum, a cap-assisted colonoscopy technique was used. After submucosal injection into the base of the mass, a snare polypectomy was performed within the ileum (). And then, three clips were placed to prevent delayed hemorrhage or perforation (). There were no immediate complications after the polypectomy. The histopathology report confirmed a 2.6×2.7 cm subepithelial lipoma. At 2 days of fasting after the procedure, oral intake was started and the patient complained of no symptoms related to food intake. Since resection of the lipoma, her body weight has gradually restored.