2000 A Case of Gastric Intramural Hematoma Mimicking a Gastric Mass

Abstract

INTRODUCTION: Intramural hematomas in the gastrointestinal tract are uncommon, and usually described in small bowel or esophagus. Occurrence in the stomach is extremely rare especially in the absence of any trauma or underlying coagulopathy. We describe a case of a vanishing “gastric mass” found on cross-sectional imaging caused by an intramural bleed from a gastric ulcer. CASE DESCRIPTION/METHODS: A 59-year-old female with history of type 2 diabetes mellitus presented to local urgent care with 6 days of progressive epigastric pain with nausea. She reported taking acetaminophen and ibuprofen. Blood count, basic metabolic panel and chest/abdominal x ray were unremarkable. She was discharged home with opioids. She presented to the primary care physician’s office three days later without improvement, with loss of appetite and 5 lb weight loss associated with some dark stools. She was started on PPI and CT abdomen performed that showed an infiltrating mass from gastric wall around pylorus (Figure 1) highly suspicious for gastric cancer. EGD revealed two clean based 5 mm ulcers in the antrum (Figure 2). Also, an extrinsic impression was seen in the stomach at the distal gastric body and no mucosal mass lesion was seen raising possibility that the mass seen on CT was intramural. EUS was then performed and between the left lobe of the liver and the pancreas there was an irregular hyperechoic mass, doppler negative, in the wall of the stomach suggestive of an intramural hematoma. PPI was continued and repeat CT abdomen in 4 weeks showed previous mass-like lesion to have resolved (Figure 3). DISCUSSION: Gastric intramural hematomas (GIH) are extremely rare. There are 47 cases described up to date, and most are usually related to underlying coagulopathy. The reports described in the past decade have mostly been related to surgeries and procedures, making hematomas caused by peptic ulcer disease or spontaneous in less than 12% of the cases. In the era of increased radiologic imaging, findings of masses or lesions often lead to increased psychological stress to providers and patients. Though uncommon, GIH can be a relatively benign and easily manageable cause of a possible mass-like gastrointestinal lesion. Thus, thorough investigation of any mass reported on imaging should be performed prior to declaring it to be a tumor since underlying pathology can be totally benign as seen in our case.