IMAGES FOR SURGEONS ANZJSurg.com
Gastric lipoma: a rare cause of gastrointestinal bleeding A normally fit and well 72-year-old man presented to the emergency department with a sudden onset pre-syncopal episode while at home, in which he was described to be clammy, diaphoretic and pale. He reported no abdominal pain, nausea, vomiting, haematemesis, melena or fresh rectal bleeding. He was haemodynamically stable and examination was unremarkable except for a finding of melena on digital rectal examination. It was noted that his haemoglobin (Hb) had dropped from 169 g/L six months prior to admission to 99 g/L on admission. He was commenced on an intravenous proton pump inhibitor and intravenous fluids. A computed tomography (CT) scan revealed a 43-mm polypoid mass in the antrum of the stomach, consistent with a diagnosis of a gastric lipoma (Fig. 1). The following day, with ongoing melena, the patient’s Hb dropped further to 82 g/L. He was transfused two units of red blood cells and scheduled for an urgent oesophagogastroduodenoscopy. A large, submucosal, non-circumferential mass was discovered in the gastric antrum, with a central ulcer that displayed signs of recent bleeding (Fig. 2). There was no active bleeding at this time. The mass was injected with adrenaline around the margins of the ulcer. The oesophagus and duodenum were both unremarkable. Following endoscopy, the patient remained stable with no evidence of active bleeding. His case was discussed at the surgical multidisciplinary team meeting. Due to an uncertain diagnosis and the previous experience of the group indicating that such lesions are at a high risk of re-bleeding, the patient was consented for definitive surgical intervention. On day 5 following presentation, the patient underwent a midline upper abdominal laparotomy and gastrotomy with wide excision of the lesion. The lesion was located on the anterior wall of the antrum, a significant distance from the pyloric sphincter that made it
straightforward to excise and repair without concern of stenosis. A double-layered repair was performed with a full thickness layer initially and then a seromuscular layer superficially to bury the suture line. A patch of omentum was then placed over the repair and sutured in place. Histology confirmed the complete excision of a lipoma with clear margins and no evidence of malignancy (Fig. 3). The patient made a good post-operative recovery and was discharged from hospital after 3 days. Gastric lipomas are extremely rare, accounting for less than 1% of all stomach tumours.1 Their most common location is the gastric antrum.2–4 They represent less than 5% of all gastrointestinal (GI) lipomas, with most occurring in the colon.5–7 Over 90% of gastric lipomas are submucosal with the remaining being subserosal.4 They have thus far not been shown to display malignant transformation.2,3 Most are asymptomatic and are discovered incidentally. However, a small proportion are symptomatic, most commonly presenting with abdominal pain and GI bleeding.2 Additional complications including gastroduodenal intussusception and obstruction have also been reported.1 Factors increasing the likelihood that a gastric lipoma will present symptomatically include position, with tumours closer to the pylorus increasing the chance of obstruction, increased size, and, as in our patient, ulceration.1,3,7 To our knowledge, this is the first reported case of a symptomatic gastric lipoma in Australasia. Pre-resection diagnosis is difficult due to the majority of lipomas being submucosal, thereby rendering it difficult to obtain adequate tissue for histological diagnosis endoscopically.1 The most common differential based upon endoscopic findings is a submucosal gastrointestinal stromal tumour (GIST). CT imaging is a useful modality for distinguishing between lipomas and GISTs as a lipoma will typically exhibit uniform fat density within the tumour.
Fig. 1. Axial (a) and sagittal (b) views of a contrast-enhanced computed tomography scan showing a mass in the antrum of the stomach, consistent with a diagnosis of gastric lipoma.
© 2015 Royal Australasian College of Surgeons
ANZ J Surg •• (2015) ••–••
2
Images for surgeons
Surgical resection will confirm diagnosis as well as alleviate symptoms. Currently, the gold standard of care for symptomatic gastric lipomas is surgical resection.1,2,5 While there have been developments in endoscopic procedures and techniques, more research is needed to ascertain their safety and efficacy. Furthermore, despite remaining a rare cause of GI bleeding, gastric lipomas should be included in the list of differential diagnoses, as prompt diagnosis and subsequent surgical intervention can be life-saving.
References
Fig. 2. Endoscopic picture of a submucosal mass with central ulceration and evidence of recent bleeding. The gastric antrum leading to the pyloric sphincter is seen in the background.
1. Ramdass MJ, Mathur S, Seetahal-Maraj P, Barrow S. Gastric lipoma presenting with massive upper gastrointestinal bleeding. Case Rep. Emerg. Med. 2013; 2013: 506101. 2. Saltzman JR, Carr-Locke DL, Fink SA. Lipoma case report. MedGenMed 2005; 7: 16. 3. Regge D, Lo Bello G, Martincich L et al. A case of bleeding gastric lipoma: US, CT and MR findings. Eur. Radiol. 1999; 9: 256–8. 4. Kapetanakis S, Papathanasiou J, Fiska A et al. A 20-year-old man with large gastric lipoma – imaging, clinical symptoms, pathological findings and surgical treatment. Folia Med. (Plovdiv) 2010; 52: 67–70. 5. Sadio A, Peixoto P, Castanheira A et al. Gastric lipoma – an unusual case of upper gastrointestinal bleeding. Rev. Esp. Enferm. Dig. 2010; 102: 398–400. 6. Athanazio DA, Motta MP, Motta A, Lanat L, Athanazio PRF. A rare case of submucosa lipoma mimicking a malignant gastric tumour. J. Port. Gastroenterol. 2008; 15: 37–8. 7. Paksoy M, Boler DE, Baca B et al. Laparoscopic transgastric resection of a gastric lipoma presenting as acute gastrointestinal haemorrhage. Surg. Laparosc. Endosc. Percutan. Tech. 2005; 15: 163–5.
Prashant Kumar, MBChB, BSc Chris Gray, MBChB, FRACS Department of General Surgery, Timaru Hospital, Timaru, New Zealand doi: 10.1111/ans.13019
Fig. 3. Histology confirming a gastric lipoma with clear margins and no evidence of malignancy.
© 2015 Royal Australasian College of Surgeons
Gastric lipoma: a rare cause of gastrointestinal bleeding A normally fit and well 72-year-old man presented to the emergency department with a sudden onset pre-syncopal episode while at home, in which he was described to be clammy, diaphoretic and pale. He reported no abdominal pain, nausea, vomiting, haematemesis, melena or fresh rectal bleeding. He was haemodynamically stable and examination was unremarkable except for a finding of melena on digital rectal examination. It was noted that his haemoglobin (Hb) had dropped from 169 g/L six months prior to admission to 99 g/L on admission. He was commenced on an intravenous proton pump inhibitor and intravenous fluids. A computed tomography (CT) scan revealed a 43-mm polypoid mass in the antrum of the stomach, consistent with a diagnosis of a gastric lipoma (Fig. 1). The following day, with ongoing melena, the patient’s Hb dropped further to 82 g/L. He was transfused two units of red blood cells and scheduled for an urgent oesophagogastroduodenoscopy. A large, submucosal, non-circumferential mass was discovered in the gastric antrum, with a central ulcer that displayed signs of recent bleeding (Fig. 2). There was no active bleeding at this time. The mass was injected with adrenaline around the margins of the ulcer. The oesophagus and duodenum were both unremarkable. Following endoscopy, the patient remained stable with no evidence of active bleeding. His case was discussed at the surgical multidisciplinary team meeting. Due to an uncertain diagnosis and the previous experience of the group indicating that such lesions are at a high risk of re-bleeding, the patient was consented for definitive surgical intervention. On day 5 following presentation, the patient underwent a midline upper abdominal laparotomy and gastrotomy with wide excision of the lesion. The lesion was located on the anterior wall of the antrum, a significant distance from the pyloric sphincter that made it
straightforward to excise and repair without concern of stenosis. A double-layered repair was performed with a full thickness layer initially and then a seromuscular layer superficially to bury the suture line. A patch of omentum was then placed over the repair and sutured in place. Histology confirmed the complete excision of a lipoma with clear margins and no evidence of malignancy (Fig. 3). The patient made a good post-operative recovery and was discharged from hospital after 3 days. Gastric lipomas are extremely rare, accounting for less than 1% of all stomach tumours.1 Their most common location is the gastric antrum.2–4 They represent less than 5% of all gastrointestinal (GI) lipomas, with most occurring in the colon.5–7 Over 90% of gastric lipomas are submucosal with the remaining being subserosal.4 They have thus far not been shown to display malignant transformation.2,3 Most are asymptomatic and are discovered incidentally. However, a small proportion are symptomatic, most commonly presenting with abdominal pain and GI bleeding.2 Additional complications including gastroduodenal intussusception and obstruction have also been reported.1 Factors increasing the likelihood that a gastric lipoma will present symptomatically include position, with tumours closer to the pylorus increasing the chance of obstruction, increased size, and, as in our patient, ulceration.1,3,7 To our knowledge, this is the first reported case of a symptomatic gastric lipoma in Australasia. Pre-resection diagnosis is difficult due to the majority of lipomas being submucosal, thereby rendering it difficult to obtain adequate tissue for histological diagnosis endoscopically.1 The most common differential based upon endoscopic findings is a submucosal gastrointestinal stromal tumour (GIST). CT imaging is a useful modality for distinguishing between lipomas and GISTs as a lipoma will typically exhibit uniform fat density within the tumour.
Fig. 1. Axial (a) and sagittal (b) views of a contrast-enhanced computed tomography scan showing a mass in the antrum of the stomach, consistent with a diagnosis of gastric lipoma.
© 2015 Royal Australasian College of Surgeons
ANZ J Surg •• (2015) ••–••
2
Images for surgeons
Surgical resection will confirm diagnosis as well as alleviate symptoms. Currently, the gold standard of care for symptomatic gastric lipomas is surgical resection.1,2,5 While there have been developments in endoscopic procedures and techniques, more research is needed to ascertain their safety and efficacy. Furthermore, despite remaining a rare cause of GI bleeding, gastric lipomas should be included in the list of differential diagnoses, as prompt diagnosis and subsequent surgical intervention can be life-saving.
References
Fig. 2. Endoscopic picture of a submucosal mass with central ulceration and evidence of recent bleeding. The gastric antrum leading to the pyloric sphincter is seen in the background.
1. Ramdass MJ, Mathur S, Seetahal-Maraj P, Barrow S. Gastric lipoma presenting with massive upper gastrointestinal bleeding. Case Rep. Emerg. Med. 2013; 2013: 506101. 2. Saltzman JR, Carr-Locke DL, Fink SA. Lipoma case report. MedGenMed 2005; 7: 16. 3. Regge D, Lo Bello G, Martincich L et al. A case of bleeding gastric lipoma: US, CT and MR findings. Eur. Radiol. 1999; 9: 256–8. 4. Kapetanakis S, Papathanasiou J, Fiska A et al. A 20-year-old man with large gastric lipoma – imaging, clinical symptoms, pathological findings and surgical treatment. Folia Med. (Plovdiv) 2010; 52: 67–70. 5. Sadio A, Peixoto P, Castanheira A et al. Gastric lipoma – an unusual case of upper gastrointestinal bleeding. Rev. Esp. Enferm. Dig. 2010; 102: 398–400. 6. Athanazio DA, Motta MP, Motta A, Lanat L, Athanazio PRF. A rare case of submucosa lipoma mimicking a malignant gastric tumour. J. Port. Gastroenterol. 2008; 15: 37–8. 7. Paksoy M, Boler DE, Baca B et al. Laparoscopic transgastric resection of a gastric lipoma presenting as acute gastrointestinal haemorrhage. Surg. Laparosc. Endosc. Percutan. Tech. 2005; 15: 163–5.
Prashant Kumar, MBChB, BSc Chris Gray, MBChB, FRACS Department of General Surgery, Timaru Hospital, Timaru, New Zealand doi: 10.1111/ans.13019
Fig. 3. Histology confirming a gastric lipoma with clear margins and no evidence of malignancy.
© 2015 Royal Australasian College of Surgeons
