Partial spontaneous anal expulsion of the right colon lipoma: An exceptional diagnostic circumstance.

INTRODUCTION: Lipomas are most common benign tumors of the colon. They are asymptomatic and fortuitously discovered on a morphological examination. Rarely, they cause complications such as acute intussusception. In this article, we reported an exceptional discovery mode of right colon lipoma. CASE
PRESENTATION: A 54-year-old woman has consulted for acute abdominal pain relieved by the anus emission of a fat ball that she brought back with her. Abdominal computed tomography scan showed the remaining part of a lipoma developed in her right colon. Laparoscopic right colonic resection was performed. DISCUSSION: Colic lipomas are usually asymptomatic and surgical indication in these cases is debated, but it is indicated whenever complications occur such as acute intestinal intussusception. In this case, discovery mode was not considered as a complication because lipoma evacuation could have been complete. Radiological explorations and colonoscopy could evaluate the lesional state. When surgery is decided, intersecting therapeutic strategy of a short colonic resection guided by a colonization during colonoscopy should be considered.
CONCLUSION: The spontaneous expulsion of a colonic lipoma is very rare. Our observation showed that this expulsion may be partial. +The changes that the lipoma undergoes can evoke a malignant cause. a supplement to take care of this eventuality is necessary.

Introduction

Lipomas are the most common benign tumors of the digestive tract. They most frequently developpe in depends of the right colon where they remain most of the time asymptomatic [1]. Surgical resection of a fortuitous discovered lipoma is still a controversy. However, it is imperative when occlusive and haemorrhagic complications occur. We reported an exceptional diagnostic circumstance of digestive lipoma, which was the spontaneous anal expulsion of a tumor part. The remaining part in colonic lumen protrusion was diagnosed by endoscopy, which led to colonic resection decision. This observation showed an exceptional discovery mode of colonic lipoma, and described its adequate diagnostic and therapeutic strategy. This work has been reported in accordance with the SCARE criteria [2].

Observation

A 54 years old women, without pathological history but obese (BMI = 42), has consulted the emergency of a regional hospital for a relieved acute abdominal pain by anal expulsion of a ball Indeed, she brought with her a yellow tumor lesion expelled during stools. This incident occurred few hours after an episode of acute abdominal pain in her right iliac fossa.

She had no familial or personal digestive neoplasia; and during the preceding months there was no transit stroke or abdominal pain. At the rectal touch we did not notice any bleeding or find out any palpable rectal mass. Clinical examination was free of anomalies and her hemoglobin was 12 g/dl.

The mass brought by the patient was addressed for pathological examination, which objectified a lipoma without malignant signs.

Colonoscopy showed in the right colon an under the mucosa tumor of 5 cm which was partially necrosed and ulcerated. Biopsies were superficial and negative. The patient was then transferred to our university hospital.

Abdominal CT scan showed hypodense lesion of right colon with presence of dense areas evoking liposarcoma (Fig. 1). Endoscopic resection was widened due to the tumor large size and essentially because of the probability of liposarcoma evoked by CT scan. So she underwent a laparoscopic right colectomy performed by two experimented surgeons (Fig. 2). Lymph node dissection was carried out taking into account the probability of malignant lesion evoked by preoperative CT scan. Operative part was externalized by an incision at the level of the right iliac fossa.

Fig. 1

Abdominal TDM with injection (Frontal cut): greasy lesion of the right colon with presence of hyperdense areas which may evoke liposarcoma (arrow).

Fig. 2

The surgical open specimen: the under mucosal residual lipoma in protrusion in the intestinal lumen.

Post-operative evolution was favourable and histological exam confirmed lipomatous lesion without any sign of malignity, so the patient was discharged at the 4th day post operation.

Discussion

Benign tumors of the colon are rare, they are dominated by lipoma. In more than 75% of cases, these lesions are unique and attend the right colon, they are multiple in 10% of cases [4]. Under mucosal localisation is described in 90% of cases, it protrudes in the colonic lumen while under serous lipoma develops outside intestinal lumen [3].

Lipomatous lesions remain asymptomatic for a long time. Non-specific symptoms may occur when they measure more than 2 cm; colonic occlusion may then happen either by reducing intestinal lumen or by promoting colo-colic or ileo-colic intussusceptions in adults [5]. Low digestive haemorrhage and diarrhea are infrequent manifestations [6].

We described in this article an exceptional discovery circumstance of an under mucosa lipoma developed in the right colon. This clinical circumstance was rarely described in the literature, it consisted of spontaneous partial anal expulsion of lipoma during defecation.

Spontaneous expulsion of lipoma was described for the first time on 1940 by Backenstoe and al, and since then, nearly 20 cases have been reported under varying circumstances, most often including abdominal pain. However, multiple hypotheses exist in order to explain total or partial detachment of the lipoma [7], [8], [9].

In our case, the fall followed by the expulsion of the lipoma occurred after a large ulceration of its protruding part in the colonic lumen. The right iliac fossa pain, which was probably concomitant to the lipoma detachment, has spontaneously regressed.

The emergent CT scan did not show signs of intussusception.

Endoscopic resection by under mucosal dissection is possible for lesions less than 3 cm, but it exposes to perforation and/or haemorrhage risks [10]. Surgical colic resection is indicated for persistent colic tumoral residue, and also when a liposarcoma is suspected.

Indeed, dedifferentiated liposarcomas arise from their well-differentiated counterparts and thus exhibit cytogenetic similarities. It is difficult to diagnose dedifferentiated liposarcoma preoperatively, submucosal tumors suspected of being high-grade sarcomas need to be resected with adequate margins that include soft tissue around the firm tumor [11].

Conclusion

Spontaneous anal expulsion is an exceptional discovery circumstance of colonic lipoma. In this case, it is associated with abdominal pain. Pathological examination confirms its nature. Surgical resection of lipomatous residue is indicated because association with liposarcoma remains doubtful.

Conflict of interest

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval

The publication of this observation does not reveal any ethical problems.

Consent

Consent from the patient was obtained and the authors can provide this should the Editor ask to see it.

Author contribution

F.H: writing the paper.

MAE: data analysis or interpretation, writing the paper.

RB/revision of manuscript, language and discussion of malignat ETIOLOGY.

HF: writing the paper.

MHBK data analysis or interpretation.

MSJ: revision.

RL: REVISION.

Guarantor

Pr Fehmi hamila.