Intramural Gastric Hematoma: A Rare Presentation of a Gastrointestinal Stromal Tumor (GIST)

Abstract

Purpose: Gastrointestinal stromal tumors (GIST) are rare tumors of the GI tract, most commonly found in the stomach, derived from the interstitial cells of Cajal. GISTs are frequently asymptomatic and found incidentally on abdominal imaging or on endoscopy. Symptomatic GISTs most often present with nonspecific abdominal complaints, less commonly with overt or occult GI bleed due to ulceration of the tumor, and rarely with intramural hemorrhage. Methods: Rare case of a patient on anticoagulation presenting with an intramural gastric hematoma subsequently found to have a GIST. Results: A 74-year-old female with a history of recurrent DVTs secondary to lupus anticoagulant on chronic anticoagulation presented with acute-onset, diffuse abdominal pain associated with nausea and nonbloody emesis. Physical examination of the abdomen revealed diffuse tenderness without peritoneal signs. Abdominal CT showed a 10-cm heterogeneous mass along the greater curve of the stomach with extravasation of contrast suspicious for intramural hematoma with active bleeding. Following correction of her coagulopathy, selective angiography of the celiac trunk and superior mesenteric artery was performed revealing an avascular mass in the region of the gastric fundus but no active bleeding. EGD did not reveal any intraluminal bulge; however, EUS showed an abnormal heterogenous mass in the fourth layer of the gastric wall. Due to the concern of gastric GIST with spontaneous hemorrhage, exploratory laparatomy was performed. Surgical findings included a large hematoma in the lesser sac and necrotic tumor material along the posterior wall of the stomach extending to and involving the tail of the pancreas and splenic hilum. Pathologically, the surgical specimen was strongly positive for c-kit confirming the diagnosis of GIST. Conclusion: Initial management of an intramural hematoma consists of volume resuscitation and correction of any underlying coagulopathy. Subsequent management includes surgery vs. angiography, often dictated by the clinical urgency. Although anticoagulation alone is a previously described risk for intramural gastric hematoma, the presence of a GIST can add further risk and should be entertained as a possible co-existing condition. If feasible, gastrointestinal evaluation may add useful information prior to surgery, particularly via EUS. As in our patient, the finding of a mass arising from the fourth gastric wall layer on EUS prompted the consideration of GIST prior to surgical exploration and should be considered an integral part of the work-up if possible.