John Robinson Saltzman, MD; David L. Carr-Locke, MD, FRCP; Scott Andrew Fink, MD, MPH


January 18, 2005

Case Report

A 60-year-old man was transferred to our hospital after presenting with brisk passage of bright red blood per rectum. The patient was on warfarin for treatment of ischemic cardiomyopathy with an international normalized ratio (INR) of 4.0. He first noted the passage of bright red blood per rectum approximately 5 hours prior to presentation at an outside hospital. The patient also felt lightheaded.

On initial presentation, the patient was noted to be tachycardic to 130 beats/minute and to have orthostatic hypotension and frank red blood on rectal examination. After hemodynamic stabilization with intravenous hydration and 2 units of packed red blood cells, the patient was transferred to our hospital for further management.

The patient denied any history of gastrointestinal hemorrhage. He denied recent abdominal pain, nausea, vomiting, change in bowel habits, fevers, or melena. He had never had an upper endoscopy or colonoscopy. His past medical history was significant for ischemic cardiomyopathy and atrial fibrillation necessitating chronic anticoagulation with warfarin. He also had a history of chronic renal insufficiency and a history of alcohol abuse. His surgical history was significant for a mitral valve repair with a mechanical valve, coronary artery bypass graft, and recent cardiac catheterization with intracoronary stent placement.

His medications included carvedilol, aspirin 325 mg daily, captopril, torsemide, atorvastatin, ranitidine, mexiletine, and warfarin.

Physical examination revealed an obese white man in mild distress with a blood pressure of 100/70, compared with his baseline of 150/90. His supine blood pressure was 70/50, with a heart rate in the 130s (beats/minute). His cardiac exam revealed an irregularly irregular rate with a III/VI diastolic murmur. His abdomen was nontender and nondistended. Rectal exam revealed bright red blood without appreciable masses. The remainder of his physical exam was unremarkable.

On admission, the patient had a blood urea nitrogen of 52 mg/dL and a serum creatinine level of 1.4 mg/dL. His hemoglobin was 6.0 g/dL and his hematocrit was 18%, with a mean corpuscular volume of 82.4 mcm3. His INR was 2.1 after receiving vitamin K. The remainder of his laboratory exam was unremarkable.

Over the ensuing 6 hours, the patient was transfused with 6 units of packed red blood cells. Despite these transfusions, his hematocrit remained at 17% to 20%. With fresh frozen plasma and further doses of vitamin K, his INR decreased to 1.7.

The patient underwent a tagged red blood cell scan which showed evidence of active gastrointestinal bleeding from a site in the left upper quadrant, most likely localized in the jejunum or the large bowel. He then underwent mesenteric angiography. No evidence of contrast extravasation to suggest active bleeding was seen. The patient again began to pass bright red blood per rectum. In addition, he began to experience cardiac symptoms of chest pain and evidence of a cardiac ischemic injury based on electrocardiographic findings and a rise in his troponin I.

Endoscopy was performed and revealed a soft, round, 3.0-cm submucosal mass in the gastric antrum (Figure 1).

Submucosal mass found on endoscopy.

The bleeding appeared to be due to an ulceration on the surface of the mass (Figure 2).

The mass appeared to be actively bleeding as evidenced by the overlying fresh clot.

Endoscopic clipping was performed as was injection with 1:10,000 concentration epinephrine to achieve hemostasis (Figures 3 and 4).

Bleeding was controlled with injection and endoscopic clipping.

Hemostasis was achieved.

The hemostasis achieved was temporary and surgical consultation was obtained. The patient was brought to the operating room.

In the operating room, an oblique, 5-cm long gastrostomy was performed. Old blood was found and the tumor was easily localized in the mucosa of the anterior wall, slightly toward the greater curvature. A full-thickness resection with a 1-cm margin was performed. The patient had an uneventful recovery from surgery and experienced no further bleeding.

On pathology, the mass was 3.0 cm x 2.2 cm x 1.7 cm in size and was described as an intramural, fleshy, homogeneous, well-circumscribed, yellow-white mass.

On the surface of the mass was a 0.9-cm area of ulceration (Figure 5).

A 0.9-cm area of ulceration was found on the surface of the mass.

The microscopic appearance was consistent with a gastric lipoma (Figures 6-8).

The mass appeared grossly to contain fat on transection.

The microscopic appearance was consistent with a gastric lipoma.

High-power microscopic view.