upper gastrointestinal bleeding is a major cause of morbidity and mortality worldwide . in tanzania , upper gastrointestinal bleeding is very common with the commonest etiologies being variceal hemorrhage ( 51.3% ) and bleeding peptic ulcer disease ( 25% ) , respectively 1 . alc , a 45-year - old female presented to the gastroenterology unit of a tertiary teaching hospital in dar es salaam after having had recurrent episodes of vomiting blood . her first episode had occurred a year and half ago when she was 8  months pregnant and resulted into an intrauterine fetal death due to the ensuing severe anemia . she had another episode 8  months after the first and subsequent episodes came in quick succession a month later . these episodes began suddenly and she would vomit profusely loosing between 1 and 1.5  l of fresh blood . she denied any history of epigastric pain , loss of appetite , dysphagia , or odynophagia , abdominal pain , mouth sores , heart burn , fever , jaundice , or hematochezia . each episode was associated with easy fatigability and other symptoms of anemia ( table1 ) . she reported a history of weight loss ( 90  kg in 2012 and 70  kg in 2013 ) . in each of these episodes , she was diagnosed to be diabetic 6  years prior to the onset of this illness as part of a routine checkup . since then , she has been on regular follow - up at her diabetic clinic and well adherent to her medications ( metformin and glibenclamide ) and diet . her physical examination ( soon after an episode of vomiting ) was indicative of signs of ongoing blood loss . her vitals included bp : 100/60  mmhg , pr : 120/min , regular , feeble , rr : 20/min , temp : 36.8c , spo2 : 95% on room air , rbg 9.1 her abdominal examination did not reveal any distention , abdominal masses , or hepatosplenomegaly with a liver span of 12  cm . her investigations revealed a microcytic anemia ( hemoglobin 4.17  g / dl , mcv 76.1fl , mch 23.0  pg ) . she had a normal coagulation profile , renal profile and electrolytes , liver enzymes and amylase levels . while the differentials in her condition included common causes of upper gi bleeding like variceal hemorrhage and peptic ulcer disease , she did not have the risk factors for either condition . we argued more in favor of a gastric tumor in view of her weight loss and the progressive increase in frequency of the hematemesis suggestive of a growing lesion . upper gi endoscopy reveled a fundal mass 5 * 6  cm in diameter with a broad base extending to the proximal part of the body , with normal looking overlying mucosa and easily bleeding to touch ( fig.1 ) . a ct scan of the abdomen showed a soft tissue mass within the stomach which enhanced on contrast administration with significant narrowing of gastric lumen . approximately 5 * 6  cm mass with a broad base seen in the fundus extending to the proximal part of the body of the stomach with normal looking overlying mucosa . after endoscopic resection of the tumor failed , she was taken in for laparotomy where she underwent gastrotomy with resection of the mass with 2  cm tumor - free margins . intraoperative findings showed a multinodulated mass in the stomach anchored on the posterior wall of the fundus , infiltrating through the stomach wall , easily bleeding with a central crater . the sample was sent for histopathology and revealed a well circumscribed and capsulated tumor involving the muscularis of the stomach but sparing the mucosa and submucosa ( fig.2 ) , made up of waving and palisading spindle cells forming verocay bodies ( fig.3 ) with hyper ( antoni a areas ) and hypo ( antoni b areas ) cellular areas ( fig.4 ) . only mild pleomorphism was noted . normal gastric mucosa and submucosa separated from the tumor by a capsule ( h&e stain , low power ) . . these are bands of fusiform nuclei alternating with clear zones ( h&e stain , intermediate power ) . antoni a ( arrow ) and antoni b ( * ) areas ( h&e , high power ) . post - surgery the patient fared well and her laparotomy site healed uneventfully . at 6  months follow - up she had gained 5  kg and her hemoglobin had risen to 12  g / dl . schwannomas ( or neurinomas or neurilemmomas ) are commonest in the head and neck and rare in the gastrointestinal tract 2 . however , among gi schwannomas , the stomach is the commonest site of occurrence followed by colon and rarely the esophagus and small intestine 3 . they are slow growing mesenchymal tumors and constitute 6.3% of all gastric mesenchymal tumors and 0.2% of all gastric tumors 4 . there is a marked female preponderance ( f : m ratio 4:1 ) and commonly occurs in the fourth to sixth decade of life ( mean age 58  years ) 3 . they are most frequently asymptomatic . however , when symptomatic most common presentation includes upper gastrointestinal bleeding , abdominal discomfort , or a palpable mass 5,6 . gastrointestinal hemorrhage occurs as the growing submucosal mass compromises the blood supply to the overlying mucosa which may ulcerate secondary to ischemia or from a reduced tolerance to the gastric acidity 2,5,7 . in this patient , the progressive shortening interval between episodes was suggestive of a slow - growing mass lesion . weight loss which has been rarely associated with this tumor was very remarkable in this patient . gastric schwannomas enhance with contrast administration on ct and only rarely show degenerative changes like calcification or cystic changes 8 . on mri , they are also strongly enhancing and appear to have low to medium signal intensity on t1w and high signal intensity on t2w images 9 . endoscopic ultrasound which is most useful in identifying small tumors 10 is unavailable in our setup . there is usually a peritumoral lymphoid cuff , with palisading morphology of the spindle cells forming verocay bodies . other findings include hypercellular and hypocellular areas designated as antoni a and antoni b areas 11 . their involvement of the muscularis without involvement of the mucosa and submucosa explains the inconclusive findings which we got from endoscopic biopsy . acceptable options include local resection , wedge resection , partial , and even total gastrectomy . which option is chosen will depend on the size and location of the tumor and its relationship to surrounding structures . there is a strong argument to suggest that previously identified malignant variants of this tumor may actually have been other malignant gastric mesenchymal tumors rather than gastric schwannomas , since immunohistochemical differentiation was unavailable at the time 1417 . limited access to specialized gastroenterology and surgical care , insufficient supplies of o rh negative blood , limited histopathology and immunohistochemistry expertise , and geographic barriers are among the many factors that preclude timely diagnosis and management of such patients in tanzania . this article illustrates the first case of gastric schwannoma in tanzania and reminds us not to exclude rare entities as a cause of common clinical presentations . in conclusion , gastric schwannomas should be considered in the differential diagnosis of masses found in the stomach . it is important to distinguish them from other stomach tumors , given their excellent prognosis following resection .
key clinical messageupper gastrointestinal bleeding causes significant morbidity and mortality worldwide . 
 we report a rare case of hematemesis secondary to a gastric schwannoma in a tanzanian female . 
 gastric schwannomas should be considered in the differential diagnosis of gastric masses and distinguished from other etiologies , given their excellent postresection prognosis .