An Unusual Submucosal Tumor in a Pregnant Female

Purpose: Gastrointestinal endometriosis is uncommon, but when present usually involves the rectosigmoid and manifests as lower gastrointestinal bleeding, pelvic pain or constipation. Endometriosis involving the upper GI tract is very rare, but as this case illustrates, its presentation can be dramatic. Patient was a 35 year old G4P3 admitted at 19 weeks gestation with constant epigastric pain associated with nausea, vomiting and an episode of melena. She denied use of NSAIDs, smoking or alcohol use. Her past history was unremarkable. On examination her abdomen was benign and the stool was dark and positive for blood. Hemoglobin on admission was 7.9. EGD showed a 3 cm luminal based mass with 1 cm surface ulceration but no evidence of a visible vessel. A subsequent linear endoscopic ultrasound exam revealed a 7 × 7 cm, inhomogeneous mass with irregular outer borders located in the proximal gastric body and extending to the spleen, left hemidiaphragm and the pancreatic tail. Fine needle aspiration cytology was interpreted as suspicious for malignancy and she underwent an en bloc partial gastrectomy and splenectomy. Pathology showed endometriosis with extensive decidualization forming a mass infiltrating the gastric wall and spleen. She did well after surgery and delivered a healthy baby at term Conclusion: Endometriosis is rare outside the lower GI tract, but can present as a symptomatic, bleeding, gastric mass. Pregnancy appears to lead to rapid growth of extra-uterine endometriotic tissue. While EUS is helpful in evaluating subepithelial masses that may arise from many etiologies, FNA sampling may be unrevealing, and ultimately surgical resection is required.Figure