Lipomas of the GI tract are a benign and usually asymptomatic condition, most common in the colon with a general incidence of 0,2 to 4,4%, followed by the gastric antrum [5]. Among the benign SEL of the GI tract, they are the most common in the colon and second in the stomach [6], after leiomyomas. GI stromal tumors are the most common SEL overall [7]. Lipomas have some specific features at endoscopic imaging, such as yellowish hue and soft touch at forceps probe (pillow sign) [7] that often establish the definitive diagnosis without the need of complementary evaluation or biopsies.

If complementary investigation is required, for example when there are abnormal morphological characteristics or rapid growth, endoscopic ultrasound (EUS) is the most accurate and indicated method for this purpose. At EUS imaging, lipomas are homogeneous and hyperechoic lesions with well-defined limits arising from the submucosal layer (or third layer) [7]. Tissue samplings are usually not necessary to confirm the diagnosis when these typical characteristics are present. Submucous colonic lipomas may be sessile or pedunculated, accounting for 90% of the colorectal lipomas. The remaining 10% are subserous. 90% are in the ascending colon. Most of them are smaller than 2cm without the need for surveillance or resection. However, when larger than 4cm, 75% are symptomatic with pain, bleeding and even urgent situations such as colonic intussusception and bowel obstruction [3].

In complicated presentations, lipomas can be referred for resection and multiple options are available, from surgical treatment to many endoscopic resection techniques. Traditionally, surgical treatment was the preferred option for lesions >4cm due to its submucosal origin, and the risk of a large pedicle being formed by a serosal invagination, and could contain the deeper muscular layer, leading to a non-negligible risk of perforation in endoscopic resections [8]. However, endoscopic techniques and devices have evolved recently and now, the endoscopic approach could be the treatment of choice. The use of endoloop with or without complete snare resection using electrocautery has been described as a safe method for resection [4,7-8].

Even when complications arise, as in the case presented above, the possibility of an endoscopic resolution of the adverse event represents an evolution in therapeutic endoscopy, widening the capabilities of non-invasive procedures and avoiding surgery. Previous studies have proven that deep mural injuries and colonic perforations may be closed with endoclips [9].

Other techniques may be used for resection, such as endoscopic submucosal dissection, submucosal tunneling and endoscopic full-thickness resection, but those techniques require a specific skill set and a longer procedure duration that may not be widely available [7]. The management of colonic lipomas depend on size, location, symptoms and confirmed diagnosis, as abnormal characteristics may demand further investigation. Asymptomatic lipomas do not require follow-up or intervention. Symptomatic ones could be resected through endoscopic procedures [4,6-7].