Gastric Xanthoma (GX) as an Incidental Endoscopic Finding: A Report of 2 Cases

Abstract

Gastric xanthomas (GXs) are yellow mucosal lesions characterized by the accumulation of lipid-laden histiocytes in the lamina propria. It is usually an incidental endoscopic finding of unclear clinical significance. It has a quite variable incidence that increases with age. GX was reported to be associated with chronic gastritis, hyperplastic polyps, gastric cancer and H.pylori infection. It has been hypothesized that GX could be related to gastric injury, which was supported by the higher prevalence of gastric atrophy among reported cases. Surprisingly, no correlation between GX and hyperlipidemia was found. Case 1: A 54 year-old Caucasian female with a history of primary pulmonary hypertension and ESRD post renal and bilateral lung transplant, admitted to the hospital with epigastric pain. Vital signs were normal, physical examination was significant for mild epigastric tenderness. Laboratory work and Imaging studies were inconclusive. EGD was remarkable for a single 5 mm sessile in the gastric fundus, complete resection was accomplished. (Figure 1) Pathology results revealed GX with focal active inflammation and erosion, No Helicobacter pylori organisms identified. There was no evidence of malignancy.FigureCase 2: This is an 82 year-old male with a significant history of DM II and renal cell carcinoma, who presented to our hospital with melena. On physical examination, he looked pale and tired. Vital signs were stable, his labs were remarkable only for normocytic anemia (HB: 7.9 g/dL, MCV: 92 fL). EGD was performed next day and it revealed a mass in the gastric body and a small gastric antral polyp (Figure 2), both biopsied. Subsequently, pathology results showed clear cell carcinoma consistent with metastatic renal cell carcinoma (the mass). Gastric antral polyp biopsy was suggestive of gastric xanthoma, confirmed by immunohistochemical staining for CD68. Eventually, laparoscopic partial gastrectomy was performed successfully. GX is a rare condition of unknown etiology, there is increasing evidence on the association between GX and gastric injury. GX should be considered as a warning sign, to look for other concomitant serious conditions, most importantly gastric cancer. In our reported cases, there was no evidence of H. pylori infection or primary gastric cancer, lipid profile was normal. However, the second patient endoscopy revealed a metastatic gastric mass. We think it is prudent to look for GX gastric partners and always send for histologic confirmation.Figure