Submucous lipomas of the small intestine

S YMPTOMATIC lipomas of the small bowel are unusua1. The report of such cases serves to focus attention on the pIace of benign tumors in the differential diagnosis of intestina1 obstruction (particuIarIy by intussusception), unexplained meIena and epigastric distress. I, The rarity of benign tumors of the smaI1 bowe1 is attested by severa studies. King7 in rgr7 couId find reports of onIy 119 cases of histoIogicaIIy proved benign tumors in the Iiterature, twenty-nine of which were cases of Iipoma. WiIIis in rg2o’g cuIIed only nineteen such benign tumors from 7,492 necropsies at Boston City HospitaI and Massachusetts Genera1 HospitaI, an incidence.of I per 394 individuaIs. Kirshbaums of thezCook:County HospitaI c in Chicago found tweIve benign tumors in 5,754 necropsies from 1929 to 1934, an incidence of I per 480 persons. HaIf of his were Iipomas. In 1931 Comfort2 reported twenty-four cases of submucous Iipoma of the gastro-intestina1 tract that were encountered in the course of 3,924 necropsies performed at the Mayo Clinic. Raiford14 at Johns Hopkins HospitaI in BaItimore found fifty benign tumors, or I per 930, but to his I 1,500 necropsies he added 45,000 surgical specimens; seven of the fifty tumors were Iipomas. The incidence of subcIinica1 Iipoma of the smaI1 intestine found in the study which we report on subsequent pages was I per 325 necropsies. Ewing4 said that congenita1 predisposition of the tissue is an essentia1 factor in the orrgin of most Iipomas. He stated that the comparative isoIation of the blood suppIy of the IobuIes that reappear in Iipomas suggests that the anomaIy which predisposes to the Iesion is connected with the distribution of blood vessels in the fatty tissues. Kiilliker and ToIdt’O stated, according to Ewing, that fat Iobules have a certain independence in deveIopment which constitutes them a sort of primitive organ. No pecuIiarity in the chemica1 composition of the fat of Iipomas, no deficiency of Iipase and no grounds for the assumption that the fat of these tumors is beyond the reach of the fatmobiIizing factors of the body were found by WeIIs.l* However, since many Iipomas continue to grow whiIe the body is emaciating and not a few remain unaffected during the Ioss of body fat in tuberculosis (MadeIung12) or gastritis (Kuster”), one must assume that IocaI conditions, possibly the character of the circuIation, may prevent absorption of the Iipoma. The reIative freedom of the small intestine from stasis of fecal content, except in the termina1 portion of the ileum where the fecal materia1 accumuIates before passing into the cecum, is considered to be of significance by Raiford since the tumors in his series occurred most frequentIy in the termina1 part of the iIeum. Stasis is Iikewise found in the stomach and large intestine and these sites are aIso especiaIIy susceptibIe to invasion by a tumor. Stasis is known to be conducive to irritation; and if one accepts the irritation theory of the cause of cancer, stasis must, Raiford has said, be accepted as a contributing factor. He has further pointed out that since the small intestine deveIops chiefly during the Iatter four months of feta1 life, it is pIausibIe to assume that there is far less opportunity for arrested deveIopment and the mispIacement of embryonic tissue to occur in the small intestine than in the remainder of the gastrointestina1 tract. It is striking that Mayo and Griess’3 for a period ending December 3 I, r 947, found aImost three times as many surgicaIIy significant submucous Iipomas of the Iarge intestine