Gastric Cardia Lipoma

J Med Sci 2006;26(3):111-114
http://jms.ndmctsgh.edu.tw/2603111.pdf
Copyright © 2006 JMS
Received: July 21, 2005; Revised: October 28, 2005;
Accepted: November 15, 2005.
* Corresponding author: Cheng-Jueng Chen, Division of
General Surgery, Department of Surgery, Tri-Service General
Hospital, 325, Cheng-Gong Road Section 2, Taipei 114,
Taiwan, Republic of China. Tel: +886-2-87927191; Fax:
+886-2-87927273; E-mail: doc20227@ndmctsgh.edu.tw
Gastric Cardia Lipoma
Hao-Ming Chang 1 , Teng-Wei Chen 1 , Yi-Jen Peng 2 , Chung-Bao Hsieh 1 , De-Chuan Chan 1 ,
Jyh-Cherng Yu 1 , Yao-Chi Liu 1 , Kuo-Liang Shen 1 , and Cheng-Jueng Chen 1*
1 Division of General Surgery, Department of Surgery, 2 Department of Pathology,
Tri-Service General Hospital, National Defense Medical Center,
Taipei, Taiwan, Republic of China
Hao-Ming Chang, et al.
Here we present an extremely rare case of a gastric cardia lipoma. Lipomas are rare in the gastrointestinal tract, are usually
asymptomatic and often discovered incidentally. When a lipoma becomes larger than 4 cm, the most common indicator of
clinical presence is upper gastrointestinal hemorrhage. A 73-year-old female patient presented with melena and dysphagia.
Abdominal computed tomography revealed a gastric cardia lipoma. At laparotomy, a gastric cardia lipoma was found with
ulceration that was causing esophageal obstruction. The lipoma was removed through a gastrotomy with incision of the
mucosa and shelling out of the tumor. Recovery was uneventful.
Key words: cardia, lipoma, stomach
INTRODUCTION
Gastric lipomas are rare benign tumors. However, 6%
of all gastrointestinal tumors are classified as lipomas 1 .
The stomach is rarely affected in most cases. When present,
the most common site of involvement is the antrum (75%) 2 .
The tumor location and size most often determines the
symptomatology and the treatment methods for each case.
The rarity of this condition prompts us to report a case of
gastric cardia lipoma that was removed using a gastrotomy
approach.
CASE REPORT
The patient was a 73-year-old female who presented
with symptoms with dysphagia for solid foods and melena
for one week. No body weight loss was noted and no
abnormalities were found upon physical examination.
Laboratory data revealed normocytic anemia. Blood chemistry
profiles and coagulation studies were within normal
limits. Gastrofiberoscopy showed an elevated, round, submucosal
tumor (Fig. 1A). The tumor was located at the
esophagogastric junction, which significantly reduced the
Fig. 1 (A) Gastrofiberoscopy showed a 6 cm×5 cm, rounded,
submucosal cardia tumor; (B) CT scan showed a 6 cm×
6 cm homogeneous, well-defined, fat content cardia
tumor (arrow).
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Lipoma
lumen of the cardia. Gastrofiberoscopy showed the overlying
mucosa was smooth, and the lesion was soft and
compressible. Computed tomography (CT) revealed a
smooth, round, homogeneous, and well-encapsulated fat
tumor found over the cardia. The Hounsfield unit for this
case was–82. (Fig. 1B). Barium studies revealed a welldefined
mass-like filling defect over the posterior right
lateral aspect of the gastric cardia region.
On laparotomy, through an upper midline incision and
gastrotomy approach, a soft yellowish mass with small
ulceration in the center was identified over the posterior
aspect of the cardia (Fig. 2A). The lipoma was easily
enucleated after incision of the mucosa without damage to
the muscle layer. The mucosa was closed. Frozen section
and histopathological examination confirmed the diagnosis
of submucosal lipoma (Fig. 2B). The patient’s recovery
was uneventful.
DISCUSSION
Lipomas are rare in the gastrointestinal tract, where they
represent 6% of all gastrointestinal tumors classified 1 . The
most common site is the colon, followed by the small
intestine 3 , with the stomach rarely being affected 4,5 . The
etiology of gastric lipoma is unknown. The common view
favors embryologically sequestered adipose tissue 6 . Lipomas
are usually asymptomatic and often discovered incidentally.
It is when the lipomas become larger that they can be
manifest clinically. Symptoms are most often related to
size and location 4,7 . The most common clinical presence
(50%) is upper gastrointestinal hemorrhage caused by
pressure necrosis and ulceration of the overlying mucosa 6 .
Obstructive symptoms are also frequent (42%) and antral
lipomas may cause gastroduodenal intussu-sception 8 .
Barium studies typically reveal a smooth submucosal
mass, normal wall contractility, and changes in shape with
peristalsis 9,10 . The most reliable diagnostic tool is considered
to be a CT scan 11 , which provides more accurate data
about mass shape and structure. Lipomas are usually
homogenous and have a typical fat density ranging from–
80 to–120 Hounsfield unit. A CT scan allows a differential
diagnosis with liposarcoma, which appears either as a
heterogeneous mass containing septum, or as large areas
that appear to have variable tissue density 12 . Gastric lipomas
can be definitively diagnosed with CT in most cases,
and unnecessary endoscopy or surgery can be avoided.
Surgery is presently indicated only when malignancy
cannot be ruled out or in symptomatic patients. The choice
of treatment is based on the tumor size and location.
Endoscopic therapy is based on snare removal of small
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Fig. 2 (A) The excised specimen showed a 7 cm×6 cm
submucosal yellowish tumor with ulceration (arrows);
(B) The micrography illustrates the area of esophageal
– gastric junction. Notice the transition of glandularsquamous
mucosa and esophageal submucosal glands.
The muscularis mucosa was fragmental, and the lipoma
composed of mature adipose tissue located in the submucosal
layer (hematoxylin and eosin; magnification,
×40).
lesions less than 3 cm 13 . Although excision with simple
closure is recommended, gastrotomy with incision of the
mucosa and shelling out of the tumor may be resorted to
when it is very large or near the cardia, as wedge resection
here will destroy the esophagogastric angle and promote
reflux 14 . In emergency situations, such as massive hematemesis,
gastric resection is indicated because a diagnosis
cannot usually be confirmed. Importantly, utilizing intraoperative
frozen section can avoid unnecessary gastric
resections. Laparoscopic resection has been recommended
for lipomas less than 6 cm in diameter. Although submu-

cosal tumors can be shelled out endoscopically, a combined
laparoscopic and endoscopic approach is recommended
because the danger of bleeding and small perforations
can occur when endoscopy alone is used 15 .
In this case, CT was the main diagnostic tool and
allowed a differential diagnosis with liposarcoma, gastrointestinal
stroma tumor, angiolipoma, and lymphoma
by identifying a homogenous mass with a typical fat
density of –80 to –120 Hounsfield unit. We consider
that gastrotomy with incision of the mucosa and shelling
out of the cardia lipoma can avoid injury of the esophagogastric
angle and prevent reflux esophagitis.
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