NOTAS CLÍNICAS

 

Gastric lipoma and pyloric obstruction in a 51-year-old woman

Lipoma gástrico y obstrucción pilórica en una mujer de 51 años

 

 

W.S. Furtado¹_, D.A.C.P.G. Mello¹, V.M. Santos², T.L. Bringel¹, W.P. Oliveira Junior¹, H.J.L. Moura¹

1. General Surgery Division of Armed Forces Hospital, Brasília-DF, Brazil
2. Catholic University Medical Course and Internal Medicina Department of Armed Forces Hospital, Brasília-DF, Brazil

Dirección para correspondencia

 

 

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ABSTRACT

Gastric lipoma is considered a rare condition that may constitute a challenging diagnosis. A 51-year-old woman presented dysphagia and abdominal pain, and an upper digestive endoscopic study disclosed a gastric tumor located in the submucosa of the pyloric antrum. Conclusive diagnosis was established after repeated endoscopic biopsies, and the patient was subjected to an atypical gastrectomy, which evolved into a pyloric stenosis. This complication was appropriately corrected and the patient remains symptomless, under outpatient surveillance.

Key words: Atypical gastrectomy. Benign tumor. Gastric lipoma. Pyloric obstruction.

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RESUMEN

Lipoma gástrico es un hallazgo muy raro que suele constituir un desafío diagnóstico. Una mujer con 51 años presentó disfagia y dolor abdominal; en una endoscopia digestiva superior se encontró un tumor gástrico submucoso localizado en el antro pilórico. Se hicieron biopsias endoscópicas para establecer el diagnóstico. Esta paciente se sometió a una gastrectomía atípica, que ocasionó estenosis del píloro. Esta complicación fue adecuadamente tratada, y la paciente se mantiene sin síntomas con control ambulatorio.

Palabras clave: Gastrectomía atípica. Lipoma gástrico. Obstrucción pilórica. Tumor gástrico benigno.

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Introduction

Gastrointestinal lipomas more frequently occur in the colon (60-75%) and the small intestine (up to 31,2%)^1-7. Only 5% of them are found in the stomach, which accounts for less than 1% of the gastric tumors, and 2% to 3% of benign tumors of this organ^2,4-10. They can be under recognized or misdiagnosed by more common masses⁵ like gastrointestinal stromal tumor, leiomyoma, fibroma, neurilemmoma, adenomyoma, Brunner's gland adenoma, and heterotopic pancreas². The first description of gastric lipoma is attributed to Cruveilhier (1842)⁸. There are only about 220 cases of gastric lipomas described in the literature^2,5,8, around 10% are intramural or subserosal, while the vast majority have origin in the submucosa^5,7-10. The etiology of lipoma remains unknown^2,6,8, and it may constitute an acquired condition or an embryological misplacement⁶. The tumor is constituted by well differentiated adipocytes with a fibrous capsule, and if sectioned it grossly appears as an yellowish tissue^2,3,5,7,10. Although more commonly located in the gastric antrum (75%)², these tumors may be found at any site of the stomach^4-10. Gastric lipoma is a rare benign condition, which may mimic malignancy of the stomach.

 

Case report

A 51-year-old Brazilian woman was admitted because of a severe epigastric pain associated with episodes of vomiting, dyspepsia, dysphagia and weight loss of 5 kg during 8 months. Her body mass index was 19.81Kg/m², and the routine laboratory determinations were unremarkable. She underwent three endoscopy studies that disclosed an antral mass with around 3 cm (Fig. 1A-B). PET/CT images revealed a spherical hypoattenuating mass (31 mm x 20 mm) with fat density, without enhanced metabolism, at the antrum; and the ecoendoscopy study found a submucosal homogeneous hyperecogenic mass (27 mm x 20 mm) on the same site. The specimens obtained from two routine endoscopic biopsies revealed normal mucosa. Another biopsy was performed - guided by endoscopic ultrasound, and revealed mature fat tissue at the submucosa, and diagnosis of submucosal lipoma was characterized (Fig. 1C-D). She underwent an atypical gastrectomy by laparoscopic route, and employing linear staplers (Fig. 2A-B) to remove the gastric mass along with a wide free surgical margin. Grossly, the aspect of transected tumor was yellow and adipose (Fig. 2C-D), with a capsule. On the fifth postoperative day, the patient presented with vomiting and dysphagia, and the endoscopic evaluation revealed a pyloric substenosis, corrected by dilation. After an uneventful evolution, she was discharged to home; nevertheless, five days later, she claimed of anorexia and recurrent vomiting, and another endoscopy detected pyloric obstruction. Therefore, the patient was submitted to a pylorotomy, and was discharged to outpatient surveillance on the third postoperative day, asymptomatic and accepting solid foods.

 

 

 

 

Discussion

This 51-year-old female presented with clinical features typical of gastrointestinal obstruction and her age was in accordance with the mean age of patients at diagnosis of gastric lipomas^5,8. However, no specific symptoms could hardly contribute to raise suspicion about gastric lipoma, and the final diagnosis was based on imaging investigation and further histopathology studies. The upper digestive endoscopy showed a submucosal mass measuring about 3 cm in diameter. The first two biopsy procedures did not furnished enough tissue to histopathology analysis, phenomenon that is frequently reported in literature^3-5,8,9. The tissue samples from the third biopsy, which was guided by endoscopic ultrasound, revealed the origin of the tumor - a classical lipoma. Surgical approach was done, as most of the authors recommend for symptomatic patients^3-5,7-9,11. The occurrence of pyloric stenosis was an expected complication of the atypical gastrectomy, because the tumor resection was performed at the antrum, and with a large free surgical margin. Gastric lipomas predominate in people over than 50 years of age^2,5,8,11, and appear as solitary and asymptomatic masses^5-10. However, patients with gastric lipomatosis have been reported as an exceeding rare condition¹². The symptoms depend on localization and size of the tumor and of associated entities^2,7-10. Those lipomas developed at the antrum and the body of the stomach may origin intussusceptions into the pylorus causing obstruction and pain; while voluminous tumors may be associated with venous stasis, resulting in ulceration and hemorrhage^6-10. Lipomas larger than 2 cm usually cause symptoms (diarrhea, obstruction, intussusception, hemorrhage)^2,4,5,7,10. The most common symptoms are dyspepsia, epigastric pain, upper gastrointestinal bleeding (usually by ulceration and necrosis), obstruction and intussusception^3-11. Because of the absence of symptoms, in the vast majority of cases gastric lipoma constitutes an endoscopic finding^3,5,6,8,10, and the tumor often appears as a smooth, yellowish submucosal mass with or without ulceration^3-5,10. Classical imaging aspects like «tenting», «cushion sign» and «naked fat sign» are useful to diagnose submucosal lipomas.^2-7,11 To perform a successful endoscopic biopsy of submucosal lipomas can be a challenging task^2,4,5,9. In general, these biopsies only reveal a normal gastric mucosa^2,3,6,8,9. The use of electrocautery to elicit a local mucosal ulceration, before the biopsy procedure, might be of some utility⁵. Computerized tomography (CT) is a highly specific tool that can contribute to diagnosis^2,3-9,10. In CT images, the lipoma typically appears as a mass that is isodense (-70H to -120H) with fat^3,4,6,7,9,10. Endoscopic ultrasound is useful to diagnosis of gastric lipoma, showing the hyperecoic density of the tumor in the submucosa^2,3-10. Gastric lipomas do not have malignant potential^2,4-6,9, however, synchronous gastric carcinomas have been very rarely described^6,9. Treatment of gastric lipoma, is controversial^4,9, but resection is the best choice for symptomatic tumors^2-5,8,10. Laparoscopic route is used for tumors up to 6 cm in diameter^2,7. Pedunculated lipomas smaller than 3 cm may be excised by upper digestive endoscopy route^4,7,8,11, but mere observation is an alternative^2,4,7,10,11. Hemorrhages can be treated by endoscopic clipping⁵.

 

References

1. Calvo AM, Montón S, Rubio T, Repiso M, Sarasibar H. Invaginación intestinal en el adulto secundaria a lipoma yeyunal. An Sist Sanit Navar 2005; 28: 115-118.         [ Links ]

2. Neto FA, Ferreira MC, Bertoncello LC, Neto AA, De Aveiro WC, Bento CA, et al. Gastric lipoma presenting as a giant bulging mass in an oligosymptomatic patient: a case report. J Med Case Rep 2012;6:317.         [ Links ]

3. Penston J, Penston V. Gastric lipoma: a rare cause of iron-deficiency anaemia. BMJ Case Rep 2009; 2009. pii: bcr09.2008.0954. Epub 2009 Mar 24.         [ Links ]

4. Sadio A, Peixoto P, Castanheira A, Cancela E, Ministro P, Casimiro C, et al. Gastric lipoma - an unusual cause of upper gastrointestinal bleeding. Rev Esp Enferm Dig 2010: 102: 398-400.         [ Links ]

5. Saltzman JR, Carr-Locke DL, Fink SA. Lipoma case report. Med Gen Med 2005; 7: 16.         [ Links ]

6. Yamamoto T, Imakiire K, Hashiguchi S, Matsumoto J, Kadono J, Hamada N, et al. A rare case of gastric lipoma with early gastric cancer. Intern Med 2004;43: 1039-1041.         [ Links ]

7. Zameer M, Kanojia RP, Rao KL, Menon P, Samujh R, Thapa BR. Gastric lipoma. J Indian Assoc Pediatr Surg 2010; 15: 64-66.         [ Links ]

8. Kim DD, Tsai AI, Otani AR, Puglia CR, Malheiros CA. Lipoma gástrico: case report. Rev Col Bras Cir 2011; 38: 205-206.         [ Links ]

9. Krasniqi AS, Hoxha FT, Bicaj BX, Hashani SI, Hasimja SM, Kelmendi SM, et al. Symptomatic subserosal gastric lipoma successfully treated with enucleation. World J Gastroenterol 2008; 14: 5930-5932.         [ Links ]

10. Thompson WM, Kende AI, Levy AD. Imaging characteristics of g 10. DONE HJ. Lipoma of the stomach. Br Med J 1961; 1: 183.         [ Links ]

11. Bijlani RS, Kulkarni VM, Shahani RB, Shah HK, Dalvi A, Samsi AB. Gastric lipoma presenting as obstruction and hematemesis. J Postgrad Med 1993; 39: 42-43.         [ Links ]

 

 

Dirección para correspondencia:
Vitorino Modesto dos Santos
Hospital das Forças Armadas
Estrada do contorno do bosque, s/n
Cruzeiro Novo, 70658-900
Brasilia-DF
E-mail: vitorinomodestos@gmail.com

Recepción: 30 de octubre de 2012
Aceptación definitiva: 21 de noviembre de 2012