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Diagnostic and therapeutic approach to obscure gastrointestinal bleeding in a patient with a jejunal gastrointestinal stromal tumor: a case report.

Yuval JB, Almogy G, Doviner V, Bala M - BMC Res Notes (2014)

Bottom Line: Angiography of the superior mesenteric artery revealed a focal hypervascular mass in the jejunum, and super selective distal coil embolization of the feeding vessel was performed.Pathological results demonstrated a gastrointestinal stromal tumor with a low proliferation index of 1%.Small erosions in the adjacent mucosa confirmed the locus of bleeding.

View Article: PubMed Central - PubMed

Affiliation: Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel. rbalam@hadassah.org.il.

ABSTRACT

Background: Gastrointestinal stromal tumors of the alimentary tract may present with severe bleeding. Localization and treatment of obscure gastrointestinal bleeding is challenging in cases of negative bi-directional endoscopy.

Case presentation: A previously healthy 64-year-old Caucasian female presented with clinical signs of active gastrointestinal bleeding. Esophagogastroduodenoscopy was normal, and colonoscopy revealed passage of blood from the small bowel. Computerized tomography angiography demonstrated a hypervascular lesion with active extravasation located in the jejunum. Angiography of the superior mesenteric artery revealed a focal hypervascular mass in the jejunum, and super selective distal coil embolization of the feeding vessel was performed. When the patient was taken for laparoscopic exploration, a 2.5 cm tumor arising from the anti-mesenteric border of the proximal jejunum was identified and resected with primary anastomosis. Pathological results demonstrated a gastrointestinal stromal tumor with a low proliferation index of 1%. Small erosions in the adjacent mucosa confirmed the locus of bleeding.

Conclusions: Computerized tomography is a useful tool for initial diagnosis of submucosal alimentary tumors in patients with obscure but clinically overt gastrointestinal bleeding. Selective angiography, following positive computerized tomography findings, is an important modality to allow both localization and hemostasis in actively bleeding small bowel tumors, but the procedure carries the risk of bowel necrosis. Complete surgical resection remains the mainstay for treatment of gastrointestinal stromal tumors.

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Related in: MedlinePlus

Computerized tomography angiography demonstrated a hypervacularized small bowel tumor. The arrow is pointing to the tumor. Upon close observation contrast extravasation into the lumen can be seen.
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Fig1: Computerized tomography angiography demonstrated a hypervacularized small bowel tumor. The arrow is pointing to the tumor. Upon close observation contrast extravasation into the lumen can be seen.

Mentions: A previously healthy 64-year-old Caucasian female presented to the emergency department (ED) with melena and syncope. She showed signs of hypovolemia with a heart rate of 110 beats per minute and a blood pressure of 100/50 mmHg. Digital rectal examination demonstrated hematochezia. A nasogastric tube was inserted and revealed clear gastric contents. Initial hemoglobin and hematocrit were 9 gr% and 26% respectively. Platelet count was normal. Subsequent blood counts demonstrated a drop in hemoglobin and hematocrit to 7 gr% and 20%, accompanied by a mild thrombocytopenia of 100*109/L. She received two units of packed red blood cells and was started on intravenous proton pump inhibitors. Esophagogastroduodenoscopy (EGD) was normal up to the third part of the duodenum, while colonoscopy demonstrated passage of blood from the terminal ileum without identifying the source of bleeding. Computerized tomography angiography (CTA) revealed a mass lesion in the jejunum with active intravenous contrast extravasation (Figure 1). The patient’s unstable condition determined immediate intervention. In order to accurately mark the location of the lesion, thereby avoiding an exploratory laparotomy, the patient underwent diagnostic angiography of the superior mesenteric artery arcade system, revealing a hypervascular jejunal mass (Figure 2). Selective metal coil embolization of the feeding vessel was performed. On the same day the patient was taken to the operating theatre for a laparoscopic exploration of the abdomen. A 2.5 cm tumor arising from the anti-mesenteric border of the proximal jejunum was identified (Figure 3). The embolization coil was visualized adjacent to the bowel wall, with segmental ischemic discoloration of the serosa. Small bowel resection with primary anastomosis was performed. Postoperative course was uneventful. Pathology results showed a CD 117 positive gastrointestinal stromal tumor with a low MIB-1 proliferation index of 1% (Figure 4). Surgical margins were free of tumor. Small erosions were noted in the adjacent mucosa, the most probable source of bleeding.Figure 1


Diagnostic and therapeutic approach to obscure gastrointestinal bleeding in a patient with a jejunal gastrointestinal stromal tumor: a case report.

Yuval JB, Almogy G, Doviner V, Bala M - BMC Res Notes (2014)

Computerized tomography angiography demonstrated a hypervacularized small bowel tumor. The arrow is pointing to the tumor. Upon close observation contrast extravasation into the lumen can be seen.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4197232&req=5

Fig1: Computerized tomography angiography demonstrated a hypervacularized small bowel tumor. The arrow is pointing to the tumor. Upon close observation contrast extravasation into the lumen can be seen.
Mentions: A previously healthy 64-year-old Caucasian female presented to the emergency department (ED) with melena and syncope. She showed signs of hypovolemia with a heart rate of 110 beats per minute and a blood pressure of 100/50 mmHg. Digital rectal examination demonstrated hematochezia. A nasogastric tube was inserted and revealed clear gastric contents. Initial hemoglobin and hematocrit were 9 gr% and 26% respectively. Platelet count was normal. Subsequent blood counts demonstrated a drop in hemoglobin and hematocrit to 7 gr% and 20%, accompanied by a mild thrombocytopenia of 100*109/L. She received two units of packed red blood cells and was started on intravenous proton pump inhibitors. Esophagogastroduodenoscopy (EGD) was normal up to the third part of the duodenum, while colonoscopy demonstrated passage of blood from the terminal ileum without identifying the source of bleeding. Computerized tomography angiography (CTA) revealed a mass lesion in the jejunum with active intravenous contrast extravasation (Figure 1). The patient’s unstable condition determined immediate intervention. In order to accurately mark the location of the lesion, thereby avoiding an exploratory laparotomy, the patient underwent diagnostic angiography of the superior mesenteric artery arcade system, revealing a hypervascular jejunal mass (Figure 2). Selective metal coil embolization of the feeding vessel was performed. On the same day the patient was taken to the operating theatre for a laparoscopic exploration of the abdomen. A 2.5 cm tumor arising from the anti-mesenteric border of the proximal jejunum was identified (Figure 3). The embolization coil was visualized adjacent to the bowel wall, with segmental ischemic discoloration of the serosa. Small bowel resection with primary anastomosis was performed. Postoperative course was uneventful. Pathology results showed a CD 117 positive gastrointestinal stromal tumor with a low MIB-1 proliferation index of 1% (Figure 4). Surgical margins were free of tumor. Small erosions were noted in the adjacent mucosa, the most probable source of bleeding.Figure 1

Bottom Line: Angiography of the superior mesenteric artery revealed a focal hypervascular mass in the jejunum, and super selective distal coil embolization of the feeding vessel was performed.Pathological results demonstrated a gastrointestinal stromal tumor with a low proliferation index of 1%.Small erosions in the adjacent mucosa confirmed the locus of bleeding.

View Article: PubMed Central - PubMed

Affiliation: Department of General Surgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel. rbalam@hadassah.org.il.

ABSTRACT

Background: Gastrointestinal stromal tumors of the alimentary tract may present with severe bleeding. Localization and treatment of obscure gastrointestinal bleeding is challenging in cases of negative bi-directional endoscopy.

Case presentation: A previously healthy 64-year-old Caucasian female presented with clinical signs of active gastrointestinal bleeding. Esophagogastroduodenoscopy was normal, and colonoscopy revealed passage of blood from the small bowel. Computerized tomography angiography demonstrated a hypervascular lesion with active extravasation located in the jejunum. Angiography of the superior mesenteric artery revealed a focal hypervascular mass in the jejunum, and super selective distal coil embolization of the feeding vessel was performed. When the patient was taken for laparoscopic exploration, a 2.5 cm tumor arising from the anti-mesenteric border of the proximal jejunum was identified and resected with primary anastomosis. Pathological results demonstrated a gastrointestinal stromal tumor with a low proliferation index of 1%. Small erosions in the adjacent mucosa confirmed the locus of bleeding.

Conclusions: Computerized tomography is a useful tool for initial diagnosis of submucosal alimentary tumors in patients with obscure but clinically overt gastrointestinal bleeding. Selective angiography, following positive computerized tomography findings, is an important modality to allow both localization and hemostasis in actively bleeding small bowel tumors, but the procedure carries the risk of bowel necrosis. Complete surgical resection remains the mainstay for treatment of gastrointestinal stromal tumors.

Show MeSH
Related in: MedlinePlus