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A 79 years old man was admitted to our hospital because of recurrent anemia. He had a history of coronary intervention for angina pectoris and was administered clopidogrel sulfate and potassium warfarin. The patient had experienced three episodes of tarry stools over the 10 months before admission. He had anemia with a hemoglobin level of 7.1 mg/dL but esophagogastroduodenoscopy and colonoscopy showed no abnormal findings.

Contrast-enhanced computed tomography showed a 2.5 cm, homogeneous, low-density mass in the small intestine (Figure 1).

Figure 1: Tomography showed a mass in the small intestine.

Transrectal Double Balloon Enteroscopy (DBE) showed a 2.5 cm wide Sub-mucosal Tumor (SMT) in the middle section of the small intestine (Figure 2).

Figure 2: Enteroscopy showed a wide submucosal tumor.

The tumor was yellowish and soft with a positive cushioning sign. Ulceration was observed at the top and base of the tumor (Figure 2), suggesting the source of his bleeding. Laparoscopy-assisted small bowel resection was performed. The resected specimen was a 3.0 cm semipedunculated SMT with an obvious exposed vessel at the center of the ulcer (Figure 3).

Figure 3: Resected specimen details.

Histopathology of the resected tumor revealed a benign lipoma (Figure 4). The patient is currently doing well 4 years later without recurrence of bleeding.

Figure 4: Histopathology of the resected tumor.

Lipoma accounts for 4.6% (5/112) of all cases of small bowel tumors detected by DBE [1]. Ohmiya et al. reported that regarding positive findings on DBE in 277 patients with OGIB, ulcers or erosions were the most frequent (n=147, 55%), followed by angiodysplasia (n=64, 23%), tumor or polyps (n=60, 22%), and so on [2].

Lipoma was extremely rare cause of OGIB and only two cases (3.3%) were reported in tumor or polyps group [2]. Though the influence of antithrombotic treatment (clopidogrel sulfate and potassium warfarin) on the clinical course cannot be ignored, present case was a direct proof that lipoma of the small intestine could be a source of gastrointestinal bleeding.