Management of a rare cause of significant acute upper gastrointestinal bleeding: gastric lipoma resected by hybrid endoscopic submucosal dissection

Gastric lipomas are rare, benign, slow-growing subepithelial tumors. Most lipomas remain asymptomatic and are detected incidentally at endoscopy. Large lipomas, however, may very rarely cause significant upper gastrointestinal (GI) bleeding and warrant removal [1].

For the management of large gastric lipomas, laparoscopic excision may be required, but endoscopic techniques such as endoscopic submucosal dissection (ESD) and unroofing have also been described [1] [2].

This endoscopic video case highlights this rare cause of upper GI bleeding and its definitive management by hybrid ESD.

A 66-year-old man presented with melena, pallor, and fatigue. On admission, his hemoglobin level was 89 g/L. He underwent an upper GI endoscopy during which a 3 cm ulcerated submucosal lesion was identified at the greater curvature ([Fig. 1]). An endoscopic clip and Hemospray (Cook Medical, Winston-Salem, North Carolina, USA) were applied, and hemostasis was achieved.

Fig. 1 Gastric lipoma.

Computed tomography imaging revealed an ovoid (fat-dense) lesion measuring 25 × 15 mm, consistent with a lipoma ([Fig. 2]). Endoscopic ultrasound assessment of the lesion was subsequently performed, and showed the presence of a homogeneous and slightly hyperechoic lesion, 25 × 15 mm, arising from the hyperechoic submucosal layer. A 22 g needle was used to obtain core biopsies but unfortunately the sample was inadequate for diagnostic assessment.

Fig. 2 Abdominal computed tomography scan image: white arrow points to gastric lipoma.

Endoscopic management of the lesion was agreed and the lesion was successfully resected by hybrid ESD ([Video 1]). No immediate or delayed adverse events were encountered.

Video 1 Hybrid endoscopic submucosal dissection procedure for the endoscopic management of a gastric lipoma.

Histopathology confirmed the diagnosis of submucosal gastric lipoma, which was completely excised ([Fig. 3]). On repeat endoscopy 3 months post-procedure, a well-healed scar was seen at the site of excision.

Fig. 3 Histopathology revealed submucosal gastric lipoma. The arrow indicates the fatty tissue of the lipoma.

This video case highlights the role of hybrid ESD in the minimally invasive and definitive management of this rare submucosal cause of upper GI bleeding.

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• References

• 1 Lee KJ, Kim GH, Park DY. et al. Endoscopic resection of gastrointestinal lipomas: a single-center experience. Surg Endosc 2014; 28: 185-192
• 2 Matsushita M, Fukata N, Okazaki K. Endoscopic removal of large gastric lipomas: en bloc resection with submucosal dissection or partial resection with unroofing technique?. Dig Endosc 2013; 25: 211-212