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ImageChallenge7
October 21, 2019

Image challenge: Hemoperitoneum — From what, where and why?

What caused a 52-year-old woman to develop a spheroid mass along the lesser curvature of the stomach?
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Gastroenterology clinical image challenge: A 52-year-old woman with a history of hypertension and cholecystectomy presented to the emergency department with several hours of severe epigastric pain radiating to her back as well as nausea and vomiting. On presentation, she was hypotensive to 89/56 mm Hg, but otherwise with normal vital signs. Physical examination was notable for a pale, diaphoretic woman with significant tenderness to palpation over the upper abdomen and no appreciable rigidity or rebound. Initial laboratory studies including complete blood count, basic metabolic profile, and lactate were within normal limits. However, within six hours, the hemoglobin had decreased from 12.6 to 8.7 g/dL. Computed tomographic angiography of the thorax, abdomen and pelvis performed in the emergency department showed a 5.6-cm hypodense mass seemingly arising from the left hepatic lobe with adjacent hyperdensity consistent with hemoperitoneum (figure) and features concerning for active extravasation from the left gastric artery.

Urgent interventional radiology consultation was pursued and transfemoral fluoroscopically guided embolization of a left gastric artery ramus was performed, resulting in apparent hemostasis. During the procedure, the left gastric artery was noted to supply a large mass on the lesser curvature of the stomach containing multiple blood vessels and several adjacent pseudoaneurysms (figure). The following day, endoscopic ultrasound examination was performed demonstrating a spheroid, echovariable but primarily hypoechoic 5.6-cm subepithelial mass (figure) along the lesser curvature of the stomach. Fine needle biopsy with a curvilinear array echoendoscope was performed using the fanning technique (figure). After preliminary pathology had resulted, the patient was taken for surgical resection of the mass (figure) on the fourth day of hospitalization.

Based on the patient’s clinical history, presentation and objective findings, what is the underlying etiology of the patient’s hemoperitoneum?

To find out the diagnosis, read the full case in Gastroenterology.

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