VCUDEATH AND COMPLICATIONS CONFERENCE04/12/2012

Brief Overview of Case

Interesting case of UGI bleed BB- 86 year old woman

Introduction for Every Case Complication

none Procedure

Partial gastric resection Primary Diagnosis

Bleeding gastric tumor

Clinical History HPI:

86 yo woman found to have Afib 2 weeks prior during hospitalization for pneumonia, placed on Pradaxa

Did well at home for 2 weeks following discharge but developed loose tarry stools for ~1 day with associated fatigue and difficulty walking

Denied any anorexia, dysphagia, vomiting, constipation, hematemesis, hematochezia. She did have nausea

Presented to ED: BP 136/94 hr 108 rr 18 98% ra; Heart irregularly irregular, no murmurs, abd soft, nt, nd, rectal old blood

in vault, guaiac positive, skin with easy bruising noted Hgb of 5, plt 256 wbc 18.7BMP: Na145 K 4.7 Cl 113 CO2 26 Glc 108 bun

28 cr 0.9 Admitted to GI service, Pradaxa stopped and transfused to Hgb >8

PMH: Afib, Hypertension, Osteoarthritis PSHx: Cholecystectomy, Cataract removal Meds/Allergies: pradaxa, occasional aspirin, (metoprolol

started in hospital)/ Allergic to sulfa Social: former 1ppd smoker x30years

Clinical History On Hospital day 2 EGD was performed:

EGD findings(3/19): Stomach was entered and along the greater curvature of the body there was a mass lesion with a central ulceration. It appeared to be malignant as it was irregular in its shape. Multiple biopsies were obtained, both from around the ulceration and from within the ulceration

Biopsy findings: Benign antral mucosal with chronic active gastritis and hyperplasia

EUS findings: Lesion along greater curve in body, extending deep to submucosa, no enlarged lymph nodes noted

Given the findings of the EUS and EGD decision was made to take the patient to the operating room for a limited gastric resection

In the OR laparoscopically, the greater curvature was dissected while leaving the vessels attached to the stomach, however it was difficult to identify the location of the lesion.

Small epigastric incision was then made for placement of a GelPort however the stomach was easily delivered into the wound and a penduculated mass along the greater curvature across from the incisura

Wedge stapled resection of the part of the greater curvater including the lesion was performed after ligating the gastroepiploic vein trunks on both sides

No anastamosis was required OR findings: A 3.5 cm, pedunculated mass on the greater curvature, right

opposite the incisura.

Final Pathology

• 3x2.5cm Submucosal lipoma with mucosal ulceration

Gastric Lipomas

Rare lesion, ~5% all GI lipomas 3rd most common benign gastric tumor

(adenomatous polyp, leiomyoma); 1% 90% GI lipomas originate in the submucosa,

solitary, soft mass They are typically asymptomatic until they

approach sizes >2cm causing, intussuception, obstruction,abdominal pain, or in cases of mucosal ulceration, anemia and/or hemorrhage

Tumor is composed of well differentiated adipose tissue histologically

William M. Thompson1,2, Amir I. Kende3 Angela D. Levy1,4 Imaging Characteristics of Gastric Lipomas in 16 Adult and Pediatric Patients. AJR October 2003 vol 181 no 4 981-985

Largest series published on gastric lipomas, retrospective over 30 years multinstitutional

Most common presenting symptom was abdominal pain (50%) followed by GI bleed (38%); symptomatic lesions were 3cm and above 13% were incidental findings

They found on review of endoscopy the tumors appeared nonfatty and biopsies were noncontributory to the final pathology in most cases

They suggested that CT was more specific in identifying some lesions, giving a homogenous appearance with HU of -70-120Privileged & Confidential: Subject to Peer Review and Medical

Review Protections, O.C.G.A. 31-7-130 et seq. and 31-7-140 et seq.

—77-year-old woman with unexplained gastrointestinal bleeding.

Thompson W M et al. AJR 2003;181:981-985

©2003 by American Roentgen Ray Society

James Penston and Victoria Penston. Gastric Lipoma: a rare casue of ion deficiency anemia. BMJ Case reports 2009;

Figure 2Computed tomography scan of the upper abdomen showing a

lobulated low-density fatty lesion within the anterior wall of antrum.

Bleeding lipomas of the upper gastrointestinal tract. A diagnostic challenge.Agha FP, Dent TL, Fiddian-Green RG, Braunstein AH, Nostrant TT.Am Surg. 1985 May;51(5):279-85.

Abstract

Submucosal lipoma of the upper gastrointestinal tract is a rare benign tumor. However, it may present as both a diagnostic problem and as a life threatening lesion due to exsanguinating hemorrhage. The authors report four patients with significant upper gastrointestinal bleeding due to ulcerating lipomas. In two patients the lesions were gastric and in two patients the lesions were duodenal in origin. In no instance could the diagnosis of lipoma be accurately established short of operative intervention because of unusual morphologic features. Surgical extirpation was necessary to stop the bleeding and establish the histologic diagnosis of the tumor.

Trop Gastroenterol. 2003 Oct-Dec;24(4):213-4.Bleeding gastric lipoma: case report and review of the literature.Dargan P, Sodhi P, Jain BK.SourceDepartment of Surgery, Guru Teg Bahadur Hospital and University College of Medical Sciences, Delhi, India. puneetdargan@yahoo.com Abstract We present a rare case of a bleeding gastric

lipoma diagnosed by computed tomography. Surgical treatment was followed by an uneventful recovery. Histopathological confirmed the diagnosis.

Surg Laparosc Endosc Percutan Tech. 2005 Jun;15(3):163-5.Laparoscopic transgastric resection of a gastric lipoma presenting as acute gastrointestinal hemorrhage.Paksoy M, Böler DE, Baca B, Ertürk S, Kapan S, Bavunoglu I, Sirin F.

Abstract A 71-year-old man was admitted to the emergency unit with

upper gastrointestinal bleeding, due to a gastric lipoma, which was controlled with conservative measures. Endoscopy and computed tomography revealed a 4-cm submucosal mass located in the posterior wall of gastric antrum. The patient underwent an elective laparoscopic transgastric resection of the lipoma and discharged on postoperative day 6. Gastric lipomas are uncommon tumors that can be incidentally found. They produce symptoms similar to peptic ulcer disease and can lead to obstruction. Gastric lipomas, which may lead to life-threatening complications such as bleeding, can be safely and reliably treated by laparoscopic transgastric resection.

References

Bleeding lipomas of the upper gastrointestinal tract. A diagnostic challenge.Agha FP, Dent TL, Fiddian-Green RG, Braunstein AH, Nostrant TT.

Fernandez MJ, Davis RP, Nora PF. Gastrointestinal lipomas. Arch Surg1983 ;11 88:1081 –1083

William M. Thompson1,2, Amir I. Kende3 Angela D. Levy1,4 Imaging Characteristics of Gastric Lipomas in 16 Adult and Pediatric Patients. AJR October 2003 vol 181 no 4 981-985

Surg Laparosc Endosc Percutan Tech. 2005 Jun;15(3):163-5.Laparoscopic transgastric resection of a gastric lipoma presenting as acute gastrointestinal hemorrhage.Paksoy M, Böler DE, Baca B, Ertürk S, Kapan S, Bavunoglu I, Sirin F.