MEDICINA E CHIRURGIA Quaderni delle Conferenze Permanenti delle Facoltà di Me Presentazione, i Frati, Ricordo di Carlo Zanussi, esare Scand Conferenza Permanente dei Pr R o iatria e P.D., Manifesto di intenti, Indagine nazionale sull'insegnamento delle cure primarie nel Corso di Laurea in MEDICINA E CHIRURGIA Luciano Vettore, Pietro Gal o, Massimo Casacchia, Fabrizio
Intestinal obstruction due to a colonic lipomaStudia Medyczne Akademi wiêtokrzyskiej Ma³gorzata Nowak, Adam Kabza, Stanis³aw G³uszek Zak³ad Chirurgi i Pielêgniarstwa Klinicznego Instytut Pielêgniarstwa i Po³o¿nictwa Wydzia³ Nauk o Zdrowiu Akademi wiêtokrzyskiej w Kielcach Dyrektor: prof. dr hab. n. med. S. G³uszek Dziekan: prof. zw. dr hab. W. Dutkiewicz Oddzia³ Chirurgi Niepubliczny Zak³ad Opieki Zdrowotnej w. Aleksandra w Kielcach Ordynator: dr n. med. Andrzej Zieliñski Samodzielny Publiczny Zespó³ Zak³adów Opieki Zdrowotnej w Opatowie Oddzia³ Chirurgiczny Ordynator: lek. med. Stanis³aw Zio³o INTESTINAL OBSTRUCTION DUE TO A COLONIC LIPOMA T³uszczaki s¹ rzadkimi ³agodnymi guzami jelita grubego, najczêciej bezobjawowymi, przypadkowo stwierdzanymi podczas kolonoskopi . Wiêksze zmiany mog¹ powodowaæ niespecyficzny nawracaj¹cy ból brzucha, objawy niedro¿noci jelit, krwawienia z dolnego odcinka przewodu pokarmowego. Auto- rzy opisuj¹ dwa przypadki du¿ych t³uszczaków jelita grubego.
Autorzy opisuj¹ dwa przypadki du¿ych t³uszczaków jelita grubego. Trudnoci w przedoperacyjnym zró¿- nicowaniu miêdzy ³agodnym a z³oliwym charakterem zmian spowodowa³y, ¿e w obu przypadkach wykonano wyciêcie prawej po³owy jelita grubego.
51-letnia kobieta z guzowat¹ mas¹ w okrê¿nicy poprzecznej, stwierdzan¹ w badaniu TK jamy brzusznej.
ródoperacyjnie stwierdzono w niej wg³obienie wstêpnicy do poprzecznicy, spowodowane 6 cm t³usz- czakiem zlokalizowanym nieco powy¿ej zastawki krêtniczo-k¹tniczej.
64-letnia kobieta diagnozowana z powodu objawów krwawienia z dolnego odcinka przewodu pokarmo- wego. W trakcie kolonoskopi stwierdzono polipowat¹ zmianê wpuklaj¹c¹ siê do wiat³a k¹tnicy. Wynik badania hist.-pat. fragment luzówki jelita grubego lub polip, najprawdopodobniej hiperplastyczny, nie stwierdzono utkania guza. Trzy miesi¹ce póniej, wykonana przed planow¹ cholecystectomi¹, kon- trolna kolonoskopia wykaza³a znacz¹cy wzrost polipa k¹tnicy obejmuj¹cego zastawkê krêtniczo-k¹tni- cz¹ i zajmuj¹cego 1/3 obwodu jelita. Pacjentce wyciêto praw¹ po³owê okrê¿nicy, histopatologicznie stwier- dzono podluzówkowy t³uszczak jelita grubego.
Chocia¿ objawowe t³uszczaki zdarzaj¹ siê rzadko, aby je rozpoznaæ, trzeba pamiêtaæ o takiej mo¿liwoci.
S³owa kluczowe: t³uszczak jelita grubego, wg³obienie jelita grubego.
SUMMARYBackground Ma³gorzata Nowak, Adam Kabza, Stanis³aw G³uszek Lipomas are rare, benign tumors of the colon; they are mostly asymptomatic, often detected incidental y at colonoscopy. Larger lesions may produce nonspecific recurrent abdominal pain, intestinal obstruc- tion, rectal bleeding. The authors describe two cases of large colonic lipomas.
The authors describe two cases of large colonic lipomas. Difficulties in the preoperative differentiation between benign and malignant colonic tumours result in right hemicolectomy performed in both cases.
A 51 year old woman with tumourous mass in the transverse colon showed in abdominal CT image.
Intraoperatively she was found to have as intussusception of the ascending colon into the transverse colon caused by 6 cm in diameter lipoma located slightly above the ileocaecal valve (ICV).
A 64 year old woman, diagnosed due to symptoms of bleeding from the low segment of digestive tract, during colonoscopy was found to have a tumurous mass protruding into the lumen of the caecum. Histo- logical examination mucous samples of the colon or the polyp, likely to be hyperplastic, no tumor te- xture was found. Three month later prior to planned cholecystectomy colonoscopy inspection of the caecal lesion showed a significant growth of a polyp encircling and spreading beyond ICV to the extent of over one third of the intestine lumen. The patient was subjected to right hemiclectomy, the pathologist iden- tified submucosum lipoma of the colon.
Although symptomatic lipomas are rare, they should be remembered for diagnostic purposes.
Key words: lipoma of the colon, colonic intussusception.
The most common benign colonic tumours are adenomas whereas the second to come in the incidence rate are lipomas. The lat er develop under the mucous mem- brane, most frequently as individual neoplasms of 1 to 3 cm in diameter. Slow and insidious development at the onset facilitates with the course of time their growth into conspicuous sizes. Lipomas are diagnosed in 4% of colonoscopy examinations .
Neoplasms of 2 cm max. in diameter can be endoscopical y excised without any fol- low-up supervision [1-3]. As the lipoma is growing, apparent become complaints due to the intestinal passage disturbances induced by the intraluminal spread of the tumo- ur as wel as intestinal occlusion or bleeding from the superficial mucosal ulceration of the lipoma able to mimic a malignant lesion in the colon [4-6]. The neoplasms may also necrose showing symptoms similar to acute appendicitis . Large lipomas with first symptoms identified as paral el complications are extremely rare, and it is difficult to make an accurate preoperative diagnosis, as the authors described in their cases.
1. Female patient aged 51 was admit ed to surgery ward for a planned operation due to tumour of the transverse colon. The patient reported in the anamnesis that she had suffered from an epigastric pain and diarrhoea two months before. The same com- plaints would recur in the fol owing few weeks. An abdominal ultrasonography (USG) dated Sept. 28, 2001 showed the presence of a thick-wal ed (15 mm), oval structure, Intestinal obstruction due to a colonic lipoma most probably a fragment of the gastrointestinal tract (stomach?, transverse colon?) in the central part of the epigastrium; the rest of abdominal organs remained normal. A pa- nendoscopy showed no lesions in the oesophagus, stomach, and duodenum.
A colonoscopy dated Oct. 10, 2001 showed no pathological lesions either in the anus or in the colon up to 110 cm of its length; one week later, an abdominal computed tomo- graphy (CT) showed tumourous mass in the transverse colon image. Within the former 3 weeks, the patient lost 8 kg of weight. On admission (Oct. 22, 2001) she reported an epigastric pain, diarrhoea, smal amounts of flatus. Physical findings showed: soft ab- domen with a minor epigastric pain; a palpable mild-edged resistance spot ed slightly to the right of the median line; negative peritoneal symptoms, a lazy peristalsis. A labo- ratory examination showed Hb 10.3g%, Ht 29.8%, Er 4.1M/uL, lowered concentration of protein (4.2g/l) and of albumin (3.0g/l) in the blood serum, CEA and CA 19-9: 0.00.
The patient was subjected to surgery in Oct. 24, 2001: she was found intraoperatively to have a large tumour in the mid-transverse colon diagnosed as intussusception of the ascending colon into the transverse colon. The intussusception was partial y fixed by pushing the telescoping part of the intestine back into place and on examination of the surrounding lymph nodes, liver, stomach, remaining bowel segments, the right side of the colon was resected. Side-to-side isoperistalsic ileotransverse anastomosis was per- formed with GIA-90 and TA-55 staplers. Dissection of excised intestinal fragment re- vealed an ulcerated tumour located slightly above the ileocaecal valve (ICV), the size of 6 cm in diameter, on macroscopic section being a probable lipoma.
Result of histopathological examination: lipoma submucosum pendulum magnum coeci cum ulceratione mucosae supra tumorem et necrosi partialis. (dr med. sci.
A. Urbaniak). No complications were recorded in the postoperative course.
2. Female patient aged 64, obese, treated due to arterial hypertension and stable coronary disease, admit ed to surgery ward for a colonoscopy due to symptoms of bleeding from the low segment of gastrointestinal tract. The patient reported further in the anamnesis that she had a disturbed stool frequency, persistent flatulence, hypo- gastric obstructions. The colonoscopy was performed: the colon was inspected al along its length; ICV remained unrevealed due to the large overlying tumourous mass pro- truding into the lumen of the caecum with no mucous lesions observable sampling was performed for histopathological examination; furthermore, the sigmoid colon showed individual diverticula and a large pedicled polyp of 3 cm in diameter with a rough, easily bleeding surface. The patient refused proposed polypectomy, sampling was performed; histopathological examination: adenoma tubulovil osum polyposum in fragmentis cum adenodysplasia gradus minoris (dr med. sci. A. Urbaniak).
In January 2003, the patient was subjected to endoscopic polypectomy of the sig- moid polyp; histopathological examination: adenoma tubulare cum dysplasia medio- cris et focale maioris gradus; excisio completa (dr med. sci. A. Urbaniak). Due to recurrent abdominal pain, the diagnostic procedure was supplemented by abdominal USG and endoscopy in the upper segment of digestive tract: cholelithiasis was iden- Ma³gorzata Nowak, Adam Kabza, Stanis³aw G³uszek tified; images of the oesophagus, stomach and duodenum were found to be normal.
No abnormalities were detected in the laboratory examinations. The patient refused proposed laparoscopic cholecystectomy.
In April 2003, the patent was again admit ed to surgery ward for laparoscopic cholecystectomy and additional inspection of the caecal lesion. Prior to a planned operation, a colonoscopy was performed showing significant growth of a polyp in the caecum nearby the appendix outlet was located a large sessile polyp encircling and spreading beyond ICV to the extent of over one third of the intestine perimeter. Hi- stopathological examination: minor superficial mucous samples of the colon or the polyp, likely to be hyperplastic with scant, active (++), nonspecific inflammatory infiltration and a minor stromal oedema; no tumour texture was found in the samples examined (dr med. sci. A. Urbaniak).
Due to the whole clinical picture and diagnostic difficulties as to the pathomor- phological quality of the caecal lesion, the patient was offered and subjected to right hemicolectomy with a paral el cholecystectomy.
In the patient was intraoperatively found a caecal tumour of 10 cm in diameter growing intramural y; no lesions were revealed on the mucosa overlying the tumour.
No swol en lymph nodes of the intestinal mesentery were detected. The postoperati- ve course was complicated after 7 days by a minor suppuration of the postsurgical wound. From the inoculation was grown Enterococcus faecalis sensitive to: ampicil- lin, gentamicin, tetracycline, vancomycin, teicoplanin. No antibiotics were admini- stered as the inflammatory process of the wound was easily control ed by hydrogen peroxide solution and betadine wash respectively as wel as effective drainage.
Result of histopathological examination: lipoma submucosum intestini crassi cum ecchymosibus haemorrhagicis recentibus (dr med. sci. A. Urbaniak).
Lipomas are benign tumours of mesenchymal origin. They may be located on the whole length of digestive tract but the highest percentage of 60-65% is observed in the colon; 20-25% in the smal intestine, and the remaining 10-15% in the oesopha- gus and stomach [1, 3]. Exceptional y seldom do lipomas change into malignancy, they come from the fat cel s in the submucosa and develop intramural y: submucously in 90%, and subserously in 10% [1, 2, 4-6, 8, 9]. They may occur as individual or mul- tiple lesions (from 10 to 24%) . Colonic lipomas are equal y common in females and males. They are mainly located in the caecum and the right side of the colon, none is observed in the rectum. Lipomas are located more frequently in the right part of the colon in females, whereas in males in its left part [1, 3, 4, 8, 9]. Macroscopical y, li- pomas resemble polyps overlaid with normal mucosa. Microscopical y, they are com- posed of mature adipose tissue without atophy, and contain a slight amount of scirr- hous elements forming the stroma of the tumour. Lipomas vary in diameter from Intestinal obstruction due to a colonic lipoma 5 mm to 9 cm. In the early stage, lipomas are clinical y asymptomatic whereas in the subsequent stage diverse noncharacteristic complaints resulting from two basic lipo- mic complications are observed: obstruction due to the mass extending intraluminal- ly into the intestine and bleeding from the mucosa overlying the lesion. Patients re- port intermit ent abdominal pains with flatulence, nausea, diarrhoea or constipation.
In 35-65% of lipomas symptoms of subobstruction are typical y observed  likely to result from, as the authors described in their cases, from large sizes of the tumour or chronic intussusception of the intestine dragged by the smal er pedicled lesion.
Lipomas are after polyps the second cause of intussusception in adults. Intussuscep- tion symptoms at ributable to children i.e. palpable tumourous abdominal mass and blood in the per rectum examination are not common in adults. The disease course is mostly subacute or chronic, periodical intestinal intussusception is associated with crampy abdominal pains [1, 3, 10, 11]. Bleeding is symptomatic of ca. 30% of lipomas resulting from necrosis and ulceration of the mucosa overlying the tumour [1, 4, 6].
Bleeding from the digestive tract suggests performing a colonoscopy a primary examination in colonic pathology allowing sampling and an accurate diagnosis.
A superficial biopsy specimen does not contribute to right diagnosis. Sometimes, on the mucosa are observed ulcerated-necrotic lesions with white-yel ow adipose tissue in the bot om; English medical literature defines it as naked fat sign and indicates that the tumour may be a lipoma. The term pil ow sign il ustrates another feature of the lipoma denoting that it is circular, soft and changes its shape when pressed .
An abdominal picture is useless in uncomplicated lipomas, but it is of lit le use in in- tussusception diagnostic procedure. The double-contrast method shows no pathogno- monic symptoms for the lipoma of which transparency being higher than the surroun- ding tissues may be the cause, but it is also due to the angle established by the submu- cosal tumour against the wal of the intestine adjacent to the lipoma (it is nearly a ri- ght angle); smooth outline of the surface, mucosal folds approaching the tumour and vanishing at its borderline [5, 8]. An abdominal CT sensitive to tissue density in the tumour differentiation, is considered to be able to detect even minor lesions. Progno- sis in patients with lipomas is very favourable if the diagnosis is made before compli- cations can occur. However, the majority of such diagnoses are made incidental y at colonoscopy or laparotomy during a diagnostic workup for other medical problems.
Tumours of 2 cm max. in size can be, in safety, endoscopical y excised, larger ones may be enucleated after intestinal wal incision both in classic and laparoscopic ope- ration [1-3, 5, 12, 13]. In such cases as those presented by the authors in which no preoperative histopathological diagnosis is made and surgery is advised due to ob- struction, intussusception or suspected malignancy, surgical procedure is usual y more radical [4-6, 8]. A colonoscopy turned out to be insufficient to make a preoperative diagnosis. In one case, biopsy specimens were taken too superficial y, and in the other, the endoscopist, being probably concerned with the transverse colon tumour reported in USG, overlooked the ascending colon lipoma this very same lipoma would in two weeks time cause intussusception. Moreover, by insufflating air into the intestinal Ma³gorzata Nowak, Adam Kabza, Stanis³aw G³uszek lumen, the operator must have pushed the intussusception temporarily back into pla- ce. Likewise, a CT examination considered to be sensitive and precise was only to prove the correlation between the tumourous mass and the colon.
Although symptomatic lipomas are rare, they should be remembered for diagno- stic purposes.
Surgery was prescribed in both presented cases due to an ambiguous clinical pic- ture and suspected colonic malignancy.
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Im Vorfeld des Biodiversitätsjahres 2010:Naturschutzpolitik braucht klare politische prioritäteN!2010 ist das Internationale Jahr der Biodiversität. Der Mouvement Ecologique möchte im Vorfeld dieses Jahres mit dem vorliegenden Dokument auf eine Reihe von grundsätzlichen Problemen in der Naturschutzpolitik aufmerksam machen, die einer zielgerichteten Politik zur Erhaltung bzw. Wiederherstellung der Biodiversität derzeit zuwider laufen. Hiermit soll auch ein Aufruf an die neuen Minister des Nachhaltigkeitsministeriums gerichtet werden, die Naturschutzpolitik an konkreten Zielen zu orientieren.