Introduction: Subepithelial tumors (SETs) are frequently encountered in the gastrointestinal tract, the majority of which are asymptomatic and discovered incidentally. Characterized by location, size, and echogenicity, the diagnostic gold standard for SETs is histology and immunohistochemistry, usually via fine or core needle biopsy. There is a spectrum of imaging modalities to diagnose these tumors with two major ones being esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS). They are operator-dependent, though in the right hands EUS approaches a sensitivity of 92% and a specificity of 100%, being the most accurate method to differentiate SET location. Symptomatic masses should be resected independent of definitive diagnosis. In the case that a biopsy is not conclusive, imaging along with patient symptoms are used to guide operative intervention.
Case Description/Methods: A 64-year-old female with uncontrolled diabetes and a history of a gunshot wound status-post exploratory laparotomy and splenectomy 30 years ago presented with vomiting and epigastric pain for 24 hours. Imaging showed an exophytic, slow-growing mass that appeared to arise from the greater curve of the stomach with heterogeneous properties and extrinsic compression. A gastrointestinal stromal tumor was the most likely possible working diagnosis at the time. Multiple fine needle aspiration biopsies via EUS consistently showed non-diagnostic pathology. The location at the greater curvature of the stomach and its continual increase in size favored a neoplastic formation. However radiographic imaging features concurrently were suspicious for a hematoma formation. The patient was taken to the operating room for an en-bloc resection of the gastric mass and pathology confirmed the diagnosis of fibrosis surrounding an organizing hematoma.
Discussion: There have been multiple reports troubleshooting upper abdominal masses with inconclusive biopsies and misdiagnosed imaging modalities that have undergone definitive surgical intervention and noted to have hepatic pathology or acute gastric hematoma. However, to the best of our knowledge, this is the first case report of a chronic enlarging gastric mass as an organizing hematoma. Based on current guidelines, it is important to use multiple diagnostic tools to help guide operative intervention for nondiagnostic subepithelial gastric mass pathologies with surgery being the best definitive treatment option in symptomatic patients.
