Teaching Case

A 65-year-old white woman presented to the emergency department with the chief complaint of black tarry stools and asthenia of one week duration.

A 65-year-old white woman presented to the emergency department with the chief complaint of black tarry stools and asthenia of one week duration. She denied any nausea, vomiting, hematemesis, or abdominal pain.She took one aspirin per day for articular problems. During physical exam no abdominal pain was elicited nor was any abdominal masses palpated Initial laboratory studies revealed a hemoglobin 8,6 g/dl. The patient was then referred for esophagogastroduodenoscopy (EGD). EGD revealed a space occupying lesion that was located at the antrum of the stomach. An area of ulceration was present at the edge of the normal mucosa. Barium studies show a mass effect at the gastric antrum and an area of ulceration. The CT scan revealed a low attenuation rounded fairly well defined soft tissue mass in the gastric antrum, measuring approximately 10x5 cm in diameter. The patient was scheduled for resection of the gastric mass. At laparotomy, a very soft, rounded mass in the gastric antrum. Final pathological diagnosis determined the mass to be a submucosal lipoma with associated ulceration of the overlying mucosa..

Gastrointestinal lipomas are benign tumors of the gastrointestinal tract, constituting only 5% of all gastrointestinal tumors. The majority (60-75%) of gastrointestinal lipomas are located in the colon, followed by the small intestine (20-25%). Gastric and duodenal lipomas are extremely rare. Gastric lipomas account for only 3% of all benign neoplasms. The etiology of gastric lipomas is unknown and the incidence is equal in both sexes. 75% of gastric lipomas are located in the antrum and are usually submucosal in origin. Less than 5% are subserosal in location. Gastric lipomas are usually asymptomatic and tumor size usually dictates occurrence of symptoms. The most common presenting symptom is gastrointestinal bleeding, occurring in over 50% of patients. Endoscopy reveals a space occupying lesion with a normal overlying mucosa. . Barium studies show a mass effect, distortion of lumen, mucosal irregularity, which can be readily mistaken for malignancy especially in the elderly. A “squeeze sign” has been described to diagnose lipomas where change in contour and configuration is seen during peristalsis on fluoroscopy. Computerized tomography is highly specific for lipomas. They manifest as well circumscribed submucosal masses with a uniform fat density (-30 to -120 HU). Other gastric tumours which contain fat include angiolipoma, liposarcoma and teratoma. Malignant tumours classically show variable tissue density and septae within the mass. Gastric lipomas have never been shown to have potential for malignant transformation. Surgery is presently indicated only when malignancy cannot be ruled out or the symptoms are crippling or life threatening. The use of intraoperative frozen section can avoid unnecessary gastric resections. Simple local enucleation or partial gastric resection is sufficient to remove the lipoma without fear of relapses. Laparoscopic resection has been recommended for lipomas less than 6 cm. In our patient, surgical excision was necessary for treatment of his bleeding ulceratous lesion.