2713 Ulcerated Gastric Leiomyoma: A Rare Cause of Gastric Outlet Obstruction

Abstract

INTRODUCTION: True leiomyomas are rare tumors that can be found anywhere along the gastrointestinal tract, more commonly in the esophagus, stomach and colon. These tumors are usually asymptomatic but may present with abdominal pain and gastrointestinal bleeding. Here, we present a rare case of a gastric leiomyoma resulting in gastric outlet obstruction. CASE DESCRIPTION/METHODS: The patient is a 52-year-old male with a past medical history of Asthma, Heroin abuse, and Peptic ulcer disease who presented to the emergency department complaining of epigastric abdominal pain accompanied by non-bloody vomiting. Notable laboratory workup included a Hemoglobin of 10.3 gm/dL. Notable imaging included a computed tomography (CT) scan of the abdomen without contrast which showed large volume gastric debris suggestive of gastric outlet obstruction. This was followed by small bowel series which showed loculated barium within the stomach with no barium seen within the pylorus. Gastroenterology service was then consulted to perform an upper esophagogastroduodenoscopy. This was done and showed severe luminal distortion of the pylorus making intubation of the duodenum difficult. This was accompanied by a large, unhealed 3 cm deep cratered ulcer just beneath the incisura. Biopsies were taken which returned showing histology consistent with gastric leiomyoma. This diagnosis was supported by diffuse positive staining with SMA and desmin and negative staining with c-kit and DOG1 immunostaining. During his admission a nasogastric tube was unable to be placed due to the level of obstruction in the pylorus. He was then started on total parenteral nutrition to meet her dietary needs. The patient was then discharged home on TPN but was lost to follow up thereafter. DISCUSSION: Gastric leiomyomas represent approximately 2.5% of all gastric neoplasms and are mostly encountered in patients aged 50-70 years with no gender predilection. Most gastric leiomyomas are slow-growing and asymptomatic; therefore, they are usually found incidentally on EGD, surgical exploration, or at autopsy. Rarely will gastric leiomyomas result in gastric outlet obstruction. The gold standard for diagnosis is biopsy which will show spindle cells that display smooth muscle differentiation and stain positively to desmin and actin. Submucosal leiomyomas less than 3 cm may be followed up by periodic EGD or endoscopic ultrasound. Lesions greated than 3 cm however may require surgical or endoscopic excision to rule out malignancy.