St. Luke's University Health Network Bethlehem, PA
Brittney Shupp, DO, Hammad Liaquat, MD, Zarian Prenatt, DO, Brian Kim, DO, Hussam Tayel, MD, Lisa Stoll, MD, MPH, Gurshawn Singh, MD, Asim Ali, MD, Roderick Quiros, MD, Berhanu Geme, MD St. Luke's University Health Network, Bethlehem, PA
Introduction: Gastrointestinal stromal tumors (GISTs) are mesenchymal neoplasms that account for 1-3% of gastrointestinal (GI) tumors with less than 5% of GISTs occurring in the duodenum. We present an interesting case of a 53-year-old patient who presented with hematemesis and melena secondary to a duodenal GIST.
Case Description/Methods: A 53-year-old male presented with hematemesis and melena. He denied unintentional weight loss, family history, or NSAID use but did endorse alcohol use. At time of arrival, the patient was afebrile with stable vital signs and physical exam was unremarkable. Laboratory values revealed a hemoglobin of 12.7 g/dL and INR of 1.04. BUN was 26 mg/dL and creatinine 1.15 mg/dL. Hepatic function panel was within normal limits. The patient was taken for upper endoscopy, which revealed a 5 cm submucosal mass with an ulcerated central area and nonbleeding visible vessel (Image 1A). The mass was on the inferior wall and distal to the ampulla. Epinephrine was injected into the mass, the nonbleeding vessel was cauterized, and 3 clips were placed successfully to achieve hemostasis (Image 1B & C). The patient required a total of 6 units of packed red blood cells transfusions during his hospital stay. Subsequently, CT chest/abdomen/pelvis was performed which revealed a 3.2 x 2.5 x 4.4 cm mass in the duodenum with an exoenteric growth pattern typical of a GIST but no evidence of metastasis (Image 1 D & E). Follow up outpatient endoscopic ultrasound (EUS) with FNA of the mass was performed which confirmed diagnosis of GIST (Image 1F). The patient initially underwent 6 months of neoadjuvant chemotherapy with Gleevac given its proximity to the Ligament of Treitz and vascular structures. The tumor significantly decreased in size and the patient underwent surgery for tumor resection. Final pathology revealed a 2.6 cm tumor with negative margins and the decision was made to continue Gleevac for a total of 3 years to prevent recurrence (Image 1G-I). Now one year following resection and 8 months after restarting chemotherapy, the patient remains in remission.
Discussion: GISTs are often asymptomatic or lead to a constellation of non-specific symptoms. GI bleeding is a commonly reported symptom of GIST, but severe bleeding requiring multiple transfusions and endoscopic intervention is very uncommon. Timely diagnosis of these tumors is imperative given their malignant potential and need for surgical or endoscopic resection to allow for definitive cure.
Figure: Image 1: (A) Esophagogastroduodenoscopy (EGD) revealing a submucosal mass about 5 cm in size with a central ulcerated area and nonbleeding visible vessel. (B, C) Three clips applied during EGD to the ulcerated mass to achieve hemostasis of bleeding that resulted following cauterization of the visible vessel. (D, E) CT chest/abdomen/pelvis demonstrating a 3.2 x 2.5 x 4.4 cm mass within the transverse portion of the duodenum demonstrating an exoenteric growth pattern. (F) Endoscopic ultrasound demonstrating an oval and hypoechoic mass measuring 34 mm x 32 mm with well-defined and smooth margins in the second part of the duodenum contained within the muscularis propria. (G) Duodenal mass resection with CD117 IHC stain, 20X, diffusely positive in GIST tumor cells. (H) Duodenal mass resection with DOG1 IHC stain, 20X, diffusely positive in GIST tumor cells. (I) Duodenal mass resection, H&E stain, 40X with bland spindle cells and absent necrosis consistent with GIST, spindle cell type.
Disclosures:
Brittney Shupp indicated no relevant financial relationships.
Hammad Liaquat indicated no relevant financial relationships.
Zarian Prenatt indicated no relevant financial relationships.
Brian Kim indicated no relevant financial relationships.
Hussam Tayel indicated no relevant financial relationships.
Lisa Stoll indicated no relevant financial relationships.
Gurshawn Singh indicated no relevant financial relationships.
Asim Ali indicated no relevant financial relationships.
Roderick Quiros indicated no relevant financial relationships.
Berhanu Geme indicated no relevant financial relationships.
Brittney Shupp, DO, Hammad Liaquat, MD, Zarian Prenatt, DO, Brian Kim, DO, Hussam Tayel, MD, Lisa Stoll, MD, MPH, Gurshawn Singh, MD, Asim Ali, MD, Roderick Quiros, MD, Berhanu Geme, MD. C0350 - Not GIST Any Bleed: A Rare Case of GIST Presenting as a Gastrointestinal Bleed, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.
