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gastrointestinal bleeding: gastric polypoid extramedullary hemopoiesis Acute upper gastrointestinal hemorrhage remains a common emergency with annual incidence between 50 and 150 hospital accesses/1 population/year and a mortality rate of 7–10% [1]. Endoscopy is the first option both in diagnosis and treatment. A 35-year-old man, suffering from Cooley disease andwith a history of splenectomy, was hospitalized for two recent episodes of hematemesis with severe anemia. Emergencyesophagogastroduodenoscopy revealed a protruding, ulcerated 4-cm mass in the gastric fundus; the overlying, nonulcerated, mucosa appeared normal (●" Fig.1). Biopsies were not performed because of the risk of bleeding. A computed tomography (CT) scan confirmed the presence of a solid, partially calcified, gastric mass, and endoscopic ultrasound (EUS) showed a rounded, well defined, submucosal hypoechoic lesion. After multidisciplinary discussion, an initial endoscopic approachwas decided. A pre-cut needlewas used to create a perilesional perimeter which facilitated the insertion of a diathermic loop.The combined and alternate use of these two instruments enabled precise and complete excision of the entire mass (●" Fig.2), despitedifficulties as a resultof the lesion’s intense vascularization and solid consistency. Endoscopic clips were positioned to control two hematic leaks. Histology showed a fibrous and partly calcifiedmass with pools of erythrocytes and interspersed red and white line cell precursors (●" Fig.3,●" Fig.4) corresponding to gastric polypoid extramedullary hematopoiesis. Extramedullary hematopoiesis is a well described compensatory response to hemoglobinopathies, insufficient medullary hematopoiesis, myelofibrosis and neoplastic replacement, or destruction of the bone marrow. Gastrointestinal localizations are extremely rare and only four cases have been reported either as a single mass [2,3] or multiple localizations [4,5]. At 1-month and 6-month follow-up in our patient, the treated region appeared as a retracted scar-like area (●" Fig.5), and after 3 years, therewas complete healing. In conclusion, our study describes the first case of gastric polypoid extramedullary hematopoiesis complicating Cooley disease to be successfully treated with an endoscopic approach.

Endoscopic management of a rare cause of upper gastrointestinal bleeding: gastric polypoid extramedullary hemopoiesis