Case Report: Massive Upper Gastrointestinal Hemorrhage Due to Spontaneous Gastric Intramural Hematoma

Introduction

Gastric intramural hematoma (GIH) is an uncommon entity characterized by hemorrhage within the submucosal or muscular layers of the gastric wall. It accounts for less than 1% of all causes of upper gastrointestinal bleeding.¹ Most cases are secondary to trauma, anticoagulant use, or endoscopic procedures.^2,3 Spontaneous cases, in the absence of any precipitating factors, are exceedingly rare.⁴ This report follows the CARE (CAse REport) guidelines and describes a massive upper gastrointestinal hemorrhage due to spontaneous GIH requiring surgical intervention after failed endoscopic therapy.⁵

Case presentation

A 57-year-old male with no prior medical or medication history presented to the emergency department with hematemesis, melena, and severe epigastric pain. On admission, he was hypotensive (85/55 mmHg) and tachycardic (120 bpm). Abdominal examination revealed epigastric tenderness without peritonitis. Laboratory investigations showed a hemoglobin level of 7.2 g/dL (baseline 13.4 g/dL) with normal coagulation parameters. The patient received aggressive fluid resuscitation and transfusion of four units of packed red blood cells.

Urgent endoscopy demonstrated a large submucosal hematoma on the posterior wall of the gastric body with active oozing ( Figure 1). Endoscopic hemostasis with epinephrine injection and clipping was attempted but failed to control bleeding. A contrast-enhanced CT was not performed due to the patient’s unstable condition. Given the persistence of bleeding and hemodynamic instability, the patient underwent emergency exploratory laparotomy. A large intramural hematoma involving the gastric body was identified ( Figures 2 and 3). Partial gastrectomy with primary reconstruction was performed ( Figure 4). Histopathology revealed extensive submucosal hemorrhage without evidence of neoplasia or vascular malformation. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. At 3-month follow-up, he remained asymptomatic with no recurrence of bleeding.

Figure 1. Endoscopic view showing a large submucosal hematoma on the posterior wall of the gastric body with mucosal discoloration and active bleeding.

Figure 2. Intraoperative view demonstrating diffuse submucosal bleeding and intramural hematoma involving the posterior wall of the gastric body.

Figure 3. Operative specimen showing a large intramural hematoma with rupture of the submucosal plane and active bleeding.

Figure 4. Resected gastric specimen after partial gastrectomy showing intramural hematoma extending along the posterior wall.

All images are original and published with patient consent.

Discussion

Gastric intramural hematoma is a rare but recognized cause of upper GI bleeding. It is usually secondary to trauma, anticoagulation, or endoscopic injury.^1,2 The spontaneous variant, as seen in this case, remains extremely uncommon. The presumed mechanism involves rupture of submucosal vessels with accumulation of blood between the gastric layers.⁶

Clinical presentation typically includes hematemesis, melena, and epigastric pain. Endoscopy may mimic subepithelial lesions, varices, or tumors.⁷ Contrast-enhanced CT, when feasible, helps differentiate hematoma from other masses by showing a non-enhancing, hyperdense lesion.⁸

Management depends on the patient’s stability and the underlying etiology. Conservative treatment may suffice for stable patients, particularly those with reversible causes such as anticoagulant therapy.⁹ However, in the presence of massive bleeding or persistent hemodynamic instability, surgical management becomes mandatory.¹⁰ Interventional radiology, such as arterial embolization, may represent an alternative if available and the patient is stable enough. In our case, persistent hemorrhage despite endoscopic therapy and transfusions necessitated partial gastrectomy, which was both diagnostic and therapeutic.

This case adds to the very limited literature on spontaneous GIH requiring surgery and underlines the diagnostic challenge of differentiating it from submucosal tumors.

Conclusion

Spontaneous gastric intramural hematoma should be included in the differential diagnosis of upper gastrointestinal bleeding, even in the absence of classical risk factors. While conservative management may be effective in stable cases, prompt surgical intervention is lifesaving when endoscopic therapy fails or instability persists.

Patient consent and ethical statement

Written informed consent for publication of this case and accompanying images was obtained from the patient. Ethical approval was not required for this single case report in accordance with institutional guidelines.