Spontaneous hemoperitoneum rarely presents as the first sign of gastric tumors, including gastrointestinal stromal tumors (GISTs). However, investigators described 2 patient cases in which spontaneous hemoperitoneum originating from gastric tumors occurred without concurrent abdominal trauma, as published in the International Journal of Surgery Case Reports.

These 2 patients presented to the emergency room with acute abdominal pain, anemia, and abdominal distention. Both required imaging to determine the source of these symptoms, identify the location of active bleeding, and estimate the duration of the bleeding.

A 40-year-old male with 24-hour epigastric pain presented with pallor, dehydration, and peritoneal irritation. Lab tests demonstrated hemoglobin levels of 15.5 g/dL, and ultrasound imaging revealed moderate amounts of intra-abdominal fluid. A computed tomography (CT) scan of the abdomen detected active bleeding in the posterior stomach wall originating from a lesion that surgical wedge section removal and histological assessment labeled a plexiform fibromyxoma (PF).

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PF histology showed multinodular, plexiform growth patterns, increased vascularization, and ovoid-to-spindle cell proliferation within the myxoid stroma. Following surgery, this young patient exhibited nausea and vomiting after eating, indicating outlet obstruction. Endoscopy revealed distal stomach stenosis which resolved fully following a roux-y-anastomosis.

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A 79-year-old male presented to the emergency room after a 24-hour progression of abdominal pain, fullness, and dizziness. Lab tests revealed hemoglobin levels of 7.6 g/dL and lactates of 2.8. A CT scan revealed a large lesion in the posterior stomach wall with active bleeding.

Following an atypical gastrectomy that completely resected the tumor, the histological assessment identified the lesion as a GIST, ranked as intermediate risk on the Fletcher stratification system and low risk on the Miettinnen index. Following the resection, the patient required a blood transfusion.

Studies show that in 95% of GIST tumor cell samples, immunohistochemical analysis allows for a definitive diagnosis through detection of receptor tyrosine kinase KIT protein expression, while a small subset of GISTs involves platelet-derived growth factor receptor alpha gene mutations. Administration of imatinib following surgical resection of metastatic GISTs prolongs progression-free and overall survival.

“Rapid tumor growth with necrosis may make masses prone to spontaneous hemorrhage,” the authors said. “In the cases of an underlying malignancy, hemorrhage occurs in part due to associated coagulopathy, neovascularization from released growth factors, metastatic marrow invasion, and thrombotic microangiopathy.”

“When a patient presents with unspecific abdominal pain and spontaneous hemoperitoneum, the surgeon should consider a potential bleeding from gastric tumor that may require gastric resection,” they concluded.


Almeida JI, Lima C, Pinto P, Armas I, Santos T, Freitas C. Spontaneous hemoperitoneum as a rare presentation of gastric lesions: two case reports. Int J Surg Case Rep. Published online January 12, 2022. doi:10.1016/j.ijscr.2022.106769