Images of the month 2: A rare case of haematemesis from a gastric submucosal lesion

Discussion

The differential diagnosis in this case included mesenchymal tumours of the stomach such as GIST. However, the CT demonstrated fat density within the lesion, with a negative Hounsfield unit (HU). This makes the lesion most likely to represent either a lipoma or a liposarcoma. Gastric lipomas are rare gastric lesions, accounting for no more than 1% of gastric tumours and are usually benign in nature.¹ Most gastric lipomas are asymptomatic and often found incidentally on CT or during endoscopy. CT allows confident diagnosis of a benign lipoma showing low attenuation, fat containing homogeneous appearance which measures between −80 to −120 HU. The presence of septations or marginal defects may indicate ulceration or very rarely a liposarcoma.² Larger lesions may present with dyspepsia symptoms, gastric outlet obstruction or bleeding.² The latter is rare and only a few cases have been reported to date.^1–3 Our case illustrates rare bleeding from a large gastric lipomatous lesion due to extensive ulceration into the mucosa. The bleeding might have been aggravated by the use of the directly acting anticoagulant (edoxaban).

Management of gastric lipomas is not well described; the most common treatment modalities include partial gastrectomy, endoscopic resection or open enucleation.³ Since this patient was an elderly man with multiple co-morbidities, a more conservative approach was taken, and no resection of the mass was planned.