Large Gastric Lipoma With Lipomatous Ulceration Resulting in Gastrointestinal Bleeding Managed With Endoscopic Submucosal Dissection.

CASE REPORT

An 81-year-old male with severe chronic obstructive pulmonary disease and atrial fibrillation presented with melena of 1-week duration and a hemoglobin level of 9.7 g/dL. Upper endoscopy revealed a 7 cm subepithelial lesion with 2 clean-based ulcers (Figure 1). Biopsies from the lesion and ulcers were consistent with a lipoma, and computed tomography imaging displayed a 7 cm lipoma-like structure in the antrum of the stomach (Figure 2). Subsequent endoscopic ultrasound imaging demonstrated a homogeneous hyperechoic lesion that originated from the submucosa with no associated lymphadenopathy, again consistent with a lipoma.

Figure 1.

Endoscopic image of the submucosal mass with several areas of ulceration.

Figure 2.

Computed tomography image of the lipoma-like structure (arrow) in the antrum of the stomach.

Due to the patient's comorbidities and the size of the lesion, surgical resection, considered the standard of care for large lipomas, was deemed high risk. The patient agreed to proceed with endoscopic submucosal dissection (ESD), which enabled en-bloc resection of the lesion (Figure 3). Due to its large size, however, the lesion could not be retrieved in one piece via the esophagus and a cold snare was used to partition the lesion. The resection defect was then successfully closed via endoscopic suturing (Figure 4). Pathology revealed a submucosal lipoma with associated lipomatous ulceration, as opposed to mucosal ulceration, which is typically seen in lipomas.[1] Typically, during active ulceration, degenerative changes with local overgrowth and breakdown are seen at the mucosal surface.[2,3] However, in this case, the ulceration penetrated past the mucosa into the lipoma, which likely increased the risk of bleeding. The patient had an uneventful recovery and at 6-month follow-up, has not had any recurrent bleeding. While gastrointestinal bleeding secondary to gastric lipomas remains relatively rare, numerous case reports have described similar presentations.[4,5] This case, however, highlights several key features: (i) ESD can offer a potential endoscopic treatment for lipomas in patients at high risk for surgery, even with lesions as large as the one presented, (ii) endoscopic suturing of the post-ESD defect may help prevent ESD-related bleeding, and (iii) lipomatous ulceration suggesting ulceration down to the submucosa may increase the risk of bleeding in these lesions.[6,7]

Figure 3.

Endoscopic image of the resection site after endoscopic submucosal dissection.

Figure 4.

Endoscopic image of the defect site after endoscopic suturing.

DISCLOSURES

Author contributions: All authors contributed equally to the manuscript. S. Han is the article guarantor.

Financial disclosure: NIH T32DK007038 (SH).

Informed consent was obtained for this case report.