LAUSR

A 42-year-old male was initially evaluated in the emergency department with a 2-month history of intermittent, non-radiating, dull epigastric pain exacerbated by food intake. He also complained of postprandial fullness, nausea, and multiple episodes of vomiting. These symptoms had recurred episodically for many years. He denied any unintentional weight loss, change in bowel habits, melena, hematochezia, or hematemesis. He was a chronic heavy alcohol consumer, starting drinking at age 15, currently consuming 1 pint of whiskey/day before admission. He had a history of multiple admissions due to alcohol withdrawal, epigastric pain, and hematemesis. He had had multiple esophagogastroduodenoscopies (EGDs) in the past that had shown hiatus hernia, esophagitis, and Mallory–Weiss tears, though no cause of his recurrent epigastric pain, nausea, and vomiting had been identified. Physical examination revealed a normal appearing male with BMI of 24 kg/m2. Vital signs on admission: temperature 38 °C, respiratory rate 18/min, heart rate 106/min, blood pressure 139/94 mmHg, and oxygen saturation 95% (room air). No conjunctival pallor, scleral icterus, palmar erythema, spider angiomata, or other stigmata of chronic liver disease were observed. His lungs were clear to auscultation and percussion, and his cardiac rhythm and heart sounds were normal. The abdomen was soft with mild tenderness in the epigastrium, but no rebound tenderness or guarding. There was no palpable organomegaly, and no distension, asymmetry, palpable masses, or lymph nodes. Results of laboratory tests (with normal ranges) included: white blood cell count 11.8 × 103/μL (4.0–11.0 × 103/μL), hemoglobin 11.8 g/dL (13.5–17.7 g/dL), hematocrit 36% (42–53%), mean corpuscular volume 85 fL (80–100 fL), platelet count 155 × 103/μL (150–400 × 103/μL), and international normalized ratio (INR) 1.06 (0.8–1.3). Other laboratory results included serum concentrations of albumin 3.2 g/dL (3.4–4.7 g/dL), lipase 91 U/L (66–360 U/L), total bilirubin 0.8 (0.3–1.2 mg/dL), alkaline phosphatase 101 U/L (38–150 U/L), alanine aminotransferase 13 (14–67 U/L), and aspartate aminotransferase 25 U/L (6–58 U/L), sodium 145 mmol/L (134–144 mmol/L), potassium 3.0 mmol/L (3.5–5.1 mmol/L), chloride 106 mmol/L (98–111 mmol/L), bicarbonate 33 mmol/L (20–30 mmol/L), glucose 86 mg/dL (60–100 mg/dL), blood urea nitrogen(BUN) 9 mg/dL (7–31 mg/dL), and creatinine 1.26 mg/dL (0.62–1.66 mg/dL). Computed tomographic (CT) scans of the abdomen and pelvis (with intravenous contrast) showed a large frond-like heterogeneous mass at the gastric fundus near the gastroesophageal (GE) junction, measuring 5.0 cm × 3.4 cm × 2.9 cm (Fig. 1a). EGD showed a hiatus hernia and a bulge in the proximal fundic region of the stomach just below the GE junction that appeared extrinsic, with no obvious mucosal involvement. Endoscopic ultrasound (EUS) showed a large well-circumscribed 5.5 cm × 3.5 cm heterogeneous, hypoechoic, cystic-appearing lesion in the region of the gastroesophageal junction, extending into the proximal peri-gastric region, adjacent to the hiatus hernia. This lesion contained heterogeneous fluid of likely thick texture. Noted within the lesion were multiple hyperechoic streaks, suggestive of the presence of air or gas. The outer wall was well-defined, hyperechoic, and mildly thickened (Fig. 1b). The lesion appeared to originate or was adherent to the adventitia/serosa of the stomach. Under * Sameen Khalid [email protected]