Gastric lipoma: a rare cause of massive haematemesis

Abstract

Gastric lipomas are rare benign neoplasms of the stomach. These submucosal lesions and located mostly in the antral region of the stomach. Small lipomas are usually asymptomatic and are detected incidentally. When large, they may present with abdominal pain, gastrointestinal (GI) bleeding or gastric outlet obstruction. We hereby present a case of gastric lipoma in a 54-year-old man presenting with massive upper GI bleed and haemodynamic instability. The diagnosis was established with endoscopy and contrast-enhanced computed tomography of the abdomen. After resuscitation, the patient underwent laparoscopic resection of the antral lipoma.

Introduction

Lipoma is aptly called the ‘universal tumour’ because of its ubiquitous presence in the body. Gastric lipomas are infrequent and account for 5% of all alimentary tract lipoma and less than 1% of all gastric neoplasms. These are usually detected in the 5^th or 6^th decade of life and have no sex predilection.¹ Gastric lipomas may present with pain abdomen, GI bleed, outlet obstruction or dyspepsia.^2,3 Only 3 cases of gastric lipoma presenting with massive GI bleed have been published.¹ We report a case of antral lipoma that presented with severe haematemesis and was managed laparoscopically.

Case Report

A 54-year-old man presented in the emergency department with one episode of massive haematemesis. He had no previous history of GI bleeding. There was no associated comorbidity and past medical history was not significant.

At presentation, the patient was conscious, pulse rate was 115/min and blood pressure was 88/60mmHg. The patient looked pale and exhausted. Abdominal examination was unremarkable. A nasogastric tube was placed that drained 350ml of altered blood. The patient was shifted to the intensive care unit (ICU) and resuscitation was started. Three units of blood were transfused, following which his tachycardia settled and blood pressure normalised. The investigations sent at the time of admission revealed haemoglobin of 6gm% and total leucocyte count of 6,600/cmm. Platelet counts and coagulation profile were normal. After stabilisation, an endoscopy revealed a large submucosal tumour in the antrum with ulceration of overlying mucosal (Figure 1). The stomach was filled with altered blood; however, no active bleeding was seen. An abdominal computed tomography (CT) showed a large (5cm), well-circumscribed tumour in the antrum (Figure 2). The lesion had a densitometry value of −90HU, characteristic of lipoma.

Figure 1 .

Endoscopic view showing a large submucosal mass in the stomach with ulceration of overlying mucosa (arrow)

Figure 2 .

(a, b) Axial and (c) sagittal CT images of the gastric lipoma (arrows). CT = computed tomography

After stabilisation, the patient was taken up for laparoscopic resection of lipoma. Anterior gastrotomy was performed and a tumour arising from the posterior wall was exposed (Figure 3). Laparoscopic wedge resection was performed and gastrotomy closed with interrupted polyglactin sutures. An intraoperative endoscopy was done to rule out outlet narrowing. The postoperative course was uneventful. Gross and histopathological examination suggested benign lipoma (Figure 4). The patient remains symptom free at 10-month follow up.

Figure 3 .

(a, b) Intraoperative image of lipoma being excised laparoscopically

Figure 4 .

(a, b) Gross appearance of the resected specimen

Discussion

Gastric lipomas are rare extramucosal neoplasms of the stomach composed chiefly of mature adipose tissue and a fibrous capsule.⁴ They are benign in nature and malignant transformation has not been reported yet.⁵ These tumours are usually solitary and sessile in nature.

Symptoms depend on the location and size of the lesion. Smaller tumours (<4cm) are usually asymptomatic and are detected incidentally. But as these tumours grow larger they exhibit a range of symptoms from dyspepsia to life-threatening haemorrhage. Bleeding due to ischaemic ulceration of overlying mucosa is the most common symptom, especially when the lesion is >2cm.^3,6 The differential diagnosis of a gastric lipoma includes neuroendocrine tumour, gastrointestinal stromal tumour, fibroma, liposarcoma or lymphoma.

The diagnosis of gastric lipoma can be established by CT scan along with endoscopy. CT is highly specific for diagnosing lipoma; it shows a well-defined, capsulated lesion with attenuation values typically ranging between −80 and −120HU.⁷

GI endoscopy shows a sharply defined submucosal lesion with a broad base, usually located in the antrum. Mucosal ulceration may be seen in cases presenting with recent GI bleed. The so-called tenting sign can be elicited by easily retracting the mucosa overlying the tumour with biopsy forceps. The cushion sign can be demonstrated by pressing biopsy forceps against the lipoma, which produces a soft, cushioning indentation over its surface. The naked fat sign is the spillage of adipose tissue after taking deeper biopsies from the tumour surface.^1,8

Given the benign nature of these tumours, both resection and enucleation are considered equally effective. There are several reports of endoscopic management of small (<4cm) gastric submucosal tumours. However, with the advent of advanced endoscopic techniques, endoscopic resection is being performed even for larger gastric lipomas.⁹ Conventional open surgery is now reserved for special situations where suspicion of malignancy or recurrence necessitates radical surgery.^1,4 Nowadays, laparoscopic resection is being performed widely for the management of gastric tumours. Tumours located on the posterior wall of pylorus or cardia have been treated by laparoscopic intragastric resection as well.¹⁰ The best approach is thus adapted based on the location and size of the lesion. The laparoscopic approach is safe and is associated with faster recovery and better cosmetic outcomes.