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Gastric lipoma: a rare cause of gastrointestinal bleeding

A normally fit and well 72-year-old man presented to the emergency department with a sudden onset pre-syncopal episode while at home, in which he was described to be clammy, diaphoretic and pale. He reported no abdominal pain, nausea, vomiting, haematemesis, melena or fresh rectal bleeding. He was haemodynamically stable and examination was unremarkable except for a finding of melena on digital rectal examination. It was noted that his haemoglobin (Hb) had dropped from 169 g/L six months prior to admission to 99 g/L on admission. He was commenced on an intravenous proton pump inhibitor and intravenous fluids. A computed tomography (CT) scan revealed a 43-mm polypoid mass in the antrum of the stomach, consistent with a diagnosis of a gastric lipoma (Fig. 1). The following day, with ongoing melena, the patient’s Hb dropped further to 82 g/L. He was transfused two units of red blood cells and scheduled for an urgent oesophagogastroduodenoscopy. A large, submucosal, non-circumferential mass was discovered in the gastric antrum, with a central ulcer that displayed signs of recent bleeding (Fig. 2). There was no active bleeding at this time. The mass was injected with adrenaline around the margins of the ulcer. The oesophagus and duodenum were both unremarkable. Following endoscopy, the patient remained stable with no evidence of active bleeding. His case was discussed at the surgical multidisciplinary team meeting. Due to an uncertain diagnosis and the previous experience of the group indicating that such lesions are at a high risk of re-bleeding, the patient was consented for definitive surgical intervention. On day 5 following presentation, the patient underwent a midline upper abdominal laparotomy and gastrotomy with wide excision of the lesion. The lesion was located on the anterior wall of the antrum, a significant distance from the pyloric sphincter that made it straightforward to excise and repair without concern of stenosis. A double-layered repair was performed with a full thickness layer initially and then a seromuscular layer superficially to bury the suture line. A patch of omentum was then placed over the repair and sutured in place. Histology confirmed the complete excision of a lipoma with clear margins and no evidence of malignancy (Fig. 3). The patient made a good post-operative recovery and was discharged from hospital after 3 days. Gastric lipomas are extremely rare, accounting for less than 1% of all stomach tumours. Their most common location is the gastric antrum. They represent less than 5% of all gastrointestinal (GI) lipomas, with most occurring in the colon. Over 90% of gastric lipomas are submucosal with the remaining being subserosal. They have thus far not been shown to display malignant transformation. Most are asymptomatic and are discovered incidentally. However, a small proportion are symptomatic, most commonly presenting with abdominal pain and GI bleeding. Additional complications including gastroduodenal intussusception and