At the Focal Point
sushi, get to the gastroenterologist promptly where, upon EGD, a nematode larva will be seen burrowing into the gastric wall and can be extracted with a biopsy forceps; end of story.usually. If the worm traverses the pylorus, its next home may be in the ileum, where it can cause an acute eosinophilic granulomatous process that may resemble Crohn’s disease. The omentum, mesentery, pancreas, and liver also may be the site of disease, as illustrated by the case described here. Patients may exhibit a slight elevation of temperature, moderate leukocytosis, and eosinophilia. Two morsels of advice: (1) Make sure your fish are gutted promptly, because with the death of the fish, infective larvae in the GI tract of the fish migrate to its muscle tissues; (2) Seek prompt EGD should GI or allergic symptoms occur soon after a sushi delight. The word sushi in its original meaning denoted “vinegar-cured rice,” and the raw fish was just a bonus. It’s not such a bonus, however, if you get anisakidosis. Lawrence J. Brandt, MD Associate Editor for Focal Points
Chronic iron deficiency anemia caused by small-bowel lipoma
A 64-year-old man presented with fatigue and unexplained chronic iron deficiency anemia for more than a year despite iron supplementation. The initial hemoglobin value was 11.2 g/dL, with a mean corpuscular volume (MCV) of 70.9 fL, ferritin level of 9.7 ng/mL, and iron saturation of 5%. Fecal occult blood test results were positive. After a normal upper and lower endoscopy, capsule endoscopy revealed an ulcerated submucosal lesion in the mid-ileum (A). Further workup with abdominal CT demonstrated a round, 1.9-cm, fat-containing mass within
the small intestine (B). Neither retrograde nor antegrade double-balloon enteroscopy could reach the area of the mass. Because of his continued anemia, it was decided to remove the mass laparoscopically. The gross specimen showed that the mucosa overlying the lesion had ulcerated (C). Pathology showed mature fat cells and confirmed the diagnosis of a small-bowel lipoma (D). Three months later, while the patient was still on iron supplementation, his laboratory values had normalized, with a hemoglobin value of 15.9 g/dL and an MCV of 84.4 fL.
678 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 4 : 2014
www.giejournal.org
At the Focal Point
DISCLOSURE The author disclosed no financial relationships relevant to this publication.
Bryan Balmadrid, MD, Michael Gluck, MD, Virginia Mason Medical Center, Seattle, Washington, USA http://dx.doi.org/10.1016/j.gie.2013.10.048
Commentary Lipoma is the second most common benign small intestinal tumor after leiomyoma and usually is detected incidentally during evaluation of unrelated symptoms. Lipomas most commonly occur in the colon (65%-75%), followed by the small intestine (20%-25%), stomach, and esophagus, and, within the small intestine, are most frequently found in the ileum followed by the duodenum and, last, the jejunum. Lipomas present in the sixth to seventh decades of life with bleeding, obstruction, and intussusception. Surface ulceration accounts for the bleeding and usually is seen when the lipoma is larger than 2 cm; smaller lipomas typically remain asymptomatic. Explanations for the ulceration, and hence the bleeding, include tumor growth that outstrips its blood supply and causes an area of ischemia, pressure on the contralateral intestinal wall, and the trauma of peristalsis and irritation of passing foodstuffs. Lipomas are usually confined to the submucosa and appear as an extrinsic sessile protrusion into the lumen, although because of peristalsis, they may become pedunculated and present with intussusception. In older horses, lipomas most commonly develop in the mesentery, and, when pedunculated, are known to wrap around a segment of bowel, form a knot with the pedicle, and produce intestinal obstruction. In today’s society, neither fat nor fatty is considered an attractive adjective or sobriquet, but when applied to a tumor in one’s intestine, upon removal and confirmation as a lipoma, it is cause for a celebratory repast. Lawrence J. Brandt, MD Associate Editor for Focal Points
Atypical duodenal ulcer and invagination caused by a large pedunculated duodenal Brunner’s gland hamartoma
A 44-year-old man was referred to our hospital for tarry stools and fatigue. He had no history of nonsteroidal antiinflammatory drug ingestion. The patient’s hemoglobin
level was 2.1 g/dL, but his vital signs were stable. EGD showed a large, pedunculated, duodenal polyp with a lobular head (A) and an ulcer at the inferior
www.giejournal.org
Volume 79, No. 4 : 2014 GASTROINTESTINAL ENDOSCOPY 679
sushi, get to the gastroenterologist promptly where, upon EGD, a nematode larva will be seen burrowing into the gastric wall and can be extracted with a biopsy forceps; end of story.usually. If the worm traverses the pylorus, its next home may be in the ileum, where it can cause an acute eosinophilic granulomatous process that may resemble Crohn’s disease. The omentum, mesentery, pancreas, and liver also may be the site of disease, as illustrated by the case described here. Patients may exhibit a slight elevation of temperature, moderate leukocytosis, and eosinophilia. Two morsels of advice: (1) Make sure your fish are gutted promptly, because with the death of the fish, infective larvae in the GI tract of the fish migrate to its muscle tissues; (2) Seek prompt EGD should GI or allergic symptoms occur soon after a sushi delight. The word sushi in its original meaning denoted “vinegar-cured rice,” and the raw fish was just a bonus. It’s not such a bonus, however, if you get anisakidosis. Lawrence J. Brandt, MD Associate Editor for Focal Points
Chronic iron deficiency anemia caused by small-bowel lipoma
A 64-year-old man presented with fatigue and unexplained chronic iron deficiency anemia for more than a year despite iron supplementation. The initial hemoglobin value was 11.2 g/dL, with a mean corpuscular volume (MCV) of 70.9 fL, ferritin level of 9.7 ng/mL, and iron saturation of 5%. Fecal occult blood test results were positive. After a normal upper and lower endoscopy, capsule endoscopy revealed an ulcerated submucosal lesion in the mid-ileum (A). Further workup with abdominal CT demonstrated a round, 1.9-cm, fat-containing mass within
the small intestine (B). Neither retrograde nor antegrade double-balloon enteroscopy could reach the area of the mass. Because of his continued anemia, it was decided to remove the mass laparoscopically. The gross specimen showed that the mucosa overlying the lesion had ulcerated (C). Pathology showed mature fat cells and confirmed the diagnosis of a small-bowel lipoma (D). Three months later, while the patient was still on iron supplementation, his laboratory values had normalized, with a hemoglobin value of 15.9 g/dL and an MCV of 84.4 fL.
678 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 4 : 2014
www.giejournal.org
At the Focal Point
DISCLOSURE The author disclosed no financial relationships relevant to this publication.
Bryan Balmadrid, MD, Michael Gluck, MD, Virginia Mason Medical Center, Seattle, Washington, USA http://dx.doi.org/10.1016/j.gie.2013.10.048
Commentary Lipoma is the second most common benign small intestinal tumor after leiomyoma and usually is detected incidentally during evaluation of unrelated symptoms. Lipomas most commonly occur in the colon (65%-75%), followed by the small intestine (20%-25%), stomach, and esophagus, and, within the small intestine, are most frequently found in the ileum followed by the duodenum and, last, the jejunum. Lipomas present in the sixth to seventh decades of life with bleeding, obstruction, and intussusception. Surface ulceration accounts for the bleeding and usually is seen when the lipoma is larger than 2 cm; smaller lipomas typically remain asymptomatic. Explanations for the ulceration, and hence the bleeding, include tumor growth that outstrips its blood supply and causes an area of ischemia, pressure on the contralateral intestinal wall, and the trauma of peristalsis and irritation of passing foodstuffs. Lipomas are usually confined to the submucosa and appear as an extrinsic sessile protrusion into the lumen, although because of peristalsis, they may become pedunculated and present with intussusception. In older horses, lipomas most commonly develop in the mesentery, and, when pedunculated, are known to wrap around a segment of bowel, form a knot with the pedicle, and produce intestinal obstruction. In today’s society, neither fat nor fatty is considered an attractive adjective or sobriquet, but when applied to a tumor in one’s intestine, upon removal and confirmation as a lipoma, it is cause for a celebratory repast. Lawrence J. Brandt, MD Associate Editor for Focal Points
Atypical duodenal ulcer and invagination caused by a large pedunculated duodenal Brunner’s gland hamartoma
A 44-year-old man was referred to our hospital for tarry stools and fatigue. He had no history of nonsteroidal antiinflammatory drug ingestion. The patient’s hemoglobin
level was 2.1 g/dL, but his vital signs were stable. EGD showed a large, pedunculated, duodenal polyp with a lobular head (A) and an ulcer at the inferior
www.giejournal.org
Volume 79, No. 4 : 2014 GASTROINTESTINAL ENDOSCOPY 679
![[Iron deficiency anemia and anemia of chronic disease (ACD)].](/assets/img/hold.png)
