A Case Of An Obstructing Gastric Lipoma Requiring Surgical Excision

INTRODUCTION: Gastric lipomas are rare, benign tumors accounting for 3% of all benign gastric lesions. Most gastric lipomas are small, asymptomatic, and detected incidentally on radiologic evaluation or endoscopic examination. We present a rare case of a large gastric lipoma causing acute partial gastric outlet obstruction (GOO) requiring surgical excision. CASE DESCRIPTION/METHODS: A 71-year-old male was admitted for an elective endovascular abdominal aortic aneurysm (AAA) repair. Past medical history was significant for chronic obstructive pulmonary disease (COPD), AAA and hypertension. The procedure was uneventful, however, the patient developed acute hypoxia post operatively requiring high flow oxygen supplementation, worsening nausea and multiple episodes of bilious emesis. Abdominal examination was unremarkable. Laboratory examination was unremarkable except leukocytosis of 19,200/µL. Computed tomography (CT) showed scattered reticulonodular opacities in the right lower lobe and partially obstructing mass at the gastroduodenal junction with predominantly fatty attenuation. A nasogastric tube was placed for management of partial GOO and patient was started of antibiotics for treatment of suspected aspiration pneumonia. An esophagogastroduodenoscopy (EGD) with endoscopic ultrasound (EUS) was planned after hemodynamic stabilization. EGD revealed an ulcerated submucosal mass in the antrum. The scope was easily passed through the pylorus and the examined duodenum appeared normal. On EUS, the lesion was noted to be homogeneous and isoechoic, arising from the submucosa and measuring 6.0 x 2.5cm. Biopsies of the lesion were obtained, and histologic examination revealed fragments of ulcerated tissue with clusters of viable cells; no malignant cells were seen. Decision was made to proceed with surgical excision of mass due to persistent symptoms. Pathological examination confirmed the diagnosis of gastric lipoma. DISCUSSION: Gastric lipomas are slow-growing benign tumors composed of well-differentiated adipose tissue most commonly arising from the posterior wall of the antrum. Small lesions are usually asymptomatic; however, larger lesions may present with abdominal pain and overt bleeding due to ulceration of the overlying mucosa or rarely nausea and vomiting due to GOO. CT scan is an excellent modality to diagnose these lesions based on the fat density. Endoscopy may be recommended to control bleeding or obtain biopsies. Surgery may be indicated for large symptomatic lesions.Figure 1.: Gross photo demonstrating bisected submucosal mass with a tan-yellow, fatty cut surface. The overlying mucosa demonstrates a probe patent ulcer (right of image).Figure 2.: 20x magnification, H&E stain. Sections demonstrate ulcerated gastric mucosa (right of image) with a proliferation of mature adipocytes expanding the submucosa with associated fibrosis. MDM2 fluorescent in situ hybridization was negative. The findings are consistent with a gastric submucosal lipoma.