THE USE OF A WATER ENEMA IN THE VERIFICA- TION OF LIPOMA OF THE COLON*

Size: px

Start display at page:

Download "THE USE OF A WATER ENEMA IN THE VERIFICA- TION OF LIPOMA OF THE COLON*"

Douglas Morton
6 years ago
Views:

diagnosis has often been speculative until the lesion has been removed.

1 FEBRUARY, 1966 THE USE OF A WATER ENEMA IN THE VERIFICA- TION OF LIPOMA OF THE COLON* By G. MELVIN STEVENS, M.D. PAI.O ALTO, CALIFORNIA T HE suspicion of submucous lipoma of the colon may be raised by such polypoid mass features as smooth outline, sessile contour, radiolucency and variability of shape, but the true diagnosis has often been speculative until the lesion has been removed. With the use of a water enema and high contrast roentgenography one can, however, preoperatively establish the diagnosis of submucous lipoma. That such a procedure was theoretically applicable and practically useful was described by Margulis and Jovanovich3 in Their report included splendid in vitro and in vivo experiments using simulated polyps with the density of air, water, and gas. These were studied by using barium, air, double contrast, and water as contrast substances with 30, 6o, and 90 kv. exposures. The combination of a water enema and low kv. exposures took best advantage of the difference in energy absorption between the fat of the lipoma and its surrounding substance, and thereby allowed its identification. The positive identification of a lipoma of the colon may spare certain patients the unnecessary risk of surgery, and in others indicate the feasibility of local excision. This method was employed by Margulis and Jovanovich and the diagnosis of lipoma established in patients, but confidence in the radiologic diagnosis forestalled surgery. Judging from the absence of other reports on the use of water enema, it seems that the method is not well known and deserves further mention. The following report of 2 surgically verified cases confirms the reliability of the method. REPORT OF CASES CASE i. A 70 year old female complained of bloody diarrhea which had for years been recurring at approximately 6 month intervals. One month prior to admission, she had experienced severe diarrhea with io to 12 blood and mucus streaked bowel movements daily, accompanied by cramping left lower quadrant pain. There was no weight loss and no mass was palpable in the abdomen. Rectal and sigmoidoscopic examination revealed proctitis with a dry mucosa which bled rather easily. Moderate spasm of the sigmoid was encountered. A subsequent barium enema study was performed and a smooth-bordered, obstructing mass measuring 9X6 cm. was found in the lower descending colon (Fig. i, A and B). Although only a small amount of barium passed by the mass, its smooth margin, size and location suggested the possibility of a lipoma. No discernible radiolucency of the mass was present (Fig. 2). One day later, after additional preparation, a water enema was given, whereupon the lipomatous nature of the mass was confirmed roentgenographically. Figure 3, 4, B and C shows balanced exposures which were made using 6o, 85, and 120 kv. These clearly illustrate the utility of low kv. exposure, though this large lipoma can be seen in all 3 roentgenograms. At surgery, the tumor was seen attempting to intussuscept. The bowel was greatly hypertrophied immediately below the mass, apparently reflecting the attempt of the lower bowel to pull the lipoma down and expel it. Above the tumor, the bowel was normal. Several small mucosal ulcerations were present on the surface of the tumor (Fig. 4, A and B). Local resection was easily carried out. CASE II. Two days prior to admission, a year old male complained of moderately severe, diffuse, abdominal pain and slight constipation. Five days earlier he had had postprandial indigestion with diffuse abdominal discomfort. He had taken antacid and at times tranquilizer medication for relief of occasional, less severe, episodes of abdominal discomfort during the prior 2 years. Infrequent, slight rectal bleeding had been noted for at least years and * From the Department of Radiology, Palo Alto Medical Clinic, Palo Alto, California. 292

ri, #{182}6, No. Verification of Lipoma of the Colon 293 lic. 1. (A) An obstructing smooth bordered mass in the descending colon is seen on barium enema study.

A barium enema study performed 2 years before had been erroneously interpreted as being normal.

2 ri, #{182}6, No. Verification of Lipoma of the Colon 293 lic. 1. (A) An obstructing smooth bordered mass in the descending colon is seen on barium enema study. (B) TIle size, contour and shape of the mass are well demonstrated in the postevacuation roentgenogram. had been attributed to the internal hemorrhoids which were present. A barium enema study performed 2 years before had been erroneously interpreted as being normal. The Past llistorv included the removal of a lipoma from his back 1 8 sears previously, and the resection of an adenomatous polyp of the rectosigmoid 12 years ago. On physical examination, a right upper quadrant mass was believed palpable, but on the following day it had disappeared. Barium enema studs established the presence of a smooth-bordered, large, somewhat mobile, mass attached to the medial wall of the ascending colon just above the expected level of entry of the terminal ileum (lig. 5, A and B). A submucosal lipoma seemed likely and the next da, after further preparatory enemas, a (liagnostic water enema study was made. The Fic. 2. I)espite its size, the large liporna cannot be recognized by its radiolucency on barium enema roen tgenograms.

$294 G. Melvin Stevens IIRRU.\RV,.1.. ; M.S1.... i- p. I I i....\ttcr Is ItUr UI1UI1fiI rcntcll triin it.$

3 294 G. Melvin Stevens IIRRU.\RV,.1.. ; M.S1.... i- p. I I i....\ttcr Is ItUr UI1UI1fiI rcntcll triin it.1 :, i liii I (H I ks. cnnfiriii tile SllilllllIU )l1 iiia thu (1U11fl)hlttttU the lijiuii( 1 I if (i\\ kfl 5 tie tuuhiiiiie.

VoL. 96, No. 2 Verification of I.iponla of tile (olon 295 - t! t lic.

(B) The cut specimen reveals the uniform benign fatty character of the tumor. Fm. 5.

4 VoL. 96, No. 2 Verification of I.iponla of tile (olon t! t lic.. (A) A photograph of the intact tumor shows several small ulcerations of the covering mucosa. (B) The cut specimen reveals the uniform benign fatty character of the tumor. Fm. 5. (A) A large smooth-bordered ascending colon mass is seen in the barium filled colon. (B) Radiolucenc in the mass is not appreciated on a spot roentgenogram.

5 296 G. Melvin Stevens IIIBRUARY, 1966 BOKV U, 4. tic. 6. (A) A water enema study clearly demonstrates the!ipoma. Slight movement of minimal residual barium assists in fluoroscopicallv controlling filling. (B) A localized view provides improved detail of the!ipoma-water interface. persistent large radiolucency conforming to the previousls demonstrated mass left no doubt as to the lipomatous nature of the tumor (Fig. 6, A and B). The small residue of barium remaining after the preceding barium enema examination moved slightly as water filling occurred, thus assuring adequate filling of the segment in question. Subsequent surgery, with the preoperative diagnosis established, permitted a submucosal local excision of the 8.6X5.5X4.5 cm. tumor. Two or three small mucosal ulcerations overlying the lipoma undoubtedly accounted for the history of occasional bleeding (Fig. 7). DISCUSSION Of the bellign tumors of the colon, lipomas are second in frequency only to adenomas. ihe average age of patients at the time of discovery of lipomas of the colon is 6o to 6#{231} years. Approximately 90 per cent of colon lipomas are submucous, while 10 per cent are subserous.2 A water enema studs is principally, and perhaps only, of value in tile verification of the submucous variet. The fact that few lipomas are diagnosed preoperativelv, eitiler on plain roentgenograms or barium enema studies, is clear from tile reports of Ginzburg et iii. and \Vschulis et a/. In tile former report only 3 of 19 lipomaswere correctly identified and, in the latter, onls of 67 were recognized as lipomas preoperativels. Tue reason for this is the minimal radiation absorption differences between fat and the tissue of the surrounding viscera and its content in the conventional higher kv. range of diagnostic radiology. The difference in linear absorption coefficient between fat and muscle is nearly twice as great at 6o kv. as it is at 125 kv. The absorbed dose in ergs/r is onethird greater at 6o kv. than at 125 ky.4 The importance of definitive preoperative identification is obvious in ans patient who has a cofltraitldicatioll to surgery. Many lipomas are discovered only mcidentally or, in fact, accidentalk, 5 and

Voi.. (, No. 2 Verification of Lipoma of tile Colon 297 produce no symptoms. The necessity for removal of all such asymptornatic tumors might be debated.

In others whicil require surgery because of obstruction or bleeding, the lipoma mas have gross features obligating the surgeon to treat the tumor as a malignancy.

6 Voi.. (, No. 2 Verification of Lipoma of tile Colon 297 produce no symptoms. The necessity for removal of all such asymptornatic tumors might be debated. None has been known to undergo malignant transformation. In others whicil require surgery because of obstruction or bleeding, the lipoma mas have gross features obligating the surgeon to treat the tumor as a malignancy. Ten of 38 Mayo Clinic patients undergoing surgery primarily for a colon lipoma had a hem i colectonl y perfornled because of the uncertainty of the nature of the tumor. Cancer ts pe bowel resections were performed for the same reason on 6 of 19 colonic lipomas seen at tile Beth Israel Hospital of New York.5 ihe preoperative confirmation of a lipoma by the use of a tap water enema study provides for a much more prudent decision as to wilether surgery is a necessity in poor-risk patients and indicates that a local excision will suffice in tilose patients requiring surgery. SUMMARY Two cases are reported which demonstrate tile practicality of using a tap water enema alld low kilovoltage exposures as a means of confirming the presence of a submucous lipoma of tile colon. This combination of contrast and exposure magnifies the slllall radiation absorption differences of fat and water density tissue. Once identified as a lipoma, more confident and conservative management can be planned. I)epartrnent of Radiology Palo.Alto Medical Clinic 300 Homer Avenue Palo Alto, California [ic. 7. Several tiny mucosal ulcerations are seen on the surface of the locally excised liporna. REFERENCES i. Gixzuuc, L., \\EING.ARTEN, M., and IISCHER, M. G. Submucous lipoma of colon. Ann. Surg., 1958, 148, LONG, G. C., l)0ckertv, M. I)., and \VAUGH, J. 1\I. Lipoma of colon. S. C/in. North America, 1949, 29, Ms.cui.is, A. R., and Jov.AxovlcI-r, A. Roentgen diagnosis of submucous lipomas of colon. Ai. J. ROEN I GENOL., RAD. IHERA1\ & NUClEAR MED., 1960,84, I1141I S1IER5, I. \V. Effective atomic number and energy absorption in tissues. Brit. 7. Radio/., 1946, i, WVCHULIS, A. R., JACKMAN, R. J., and MAyO, C. \V. Submucous lipomas of colon and rectum. Surg., Gvnec. & Obsi., 1964, 118,

7 This article has been cited by: 1. J. Ryan, J. E. Martin, D. J. Pollock Fatty tumours of the large intestine: A clinicopathological review of 13 cases. British Journal of Surgery 76:8, [CrossRef]

Colo-Colonic Intussusception Caused by a Submucosal Lipoma

168 Colo-Colonic Intussusception Caused by a Submucosal Lipoma Case Report and Review of the Literature B.A. Twigt S.K. Nagesser D.J.A. Sonneveld Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands