Gastrointestinal stromal tumors (GIST) account for 2% of all tumors of the digestive tract. They are most frequently located in the stomach followed by the small intestine and most often present with mucosal ulceration and erosion associated with gastrointestinal bleeding. Bleeding from the small intestine can be difficult to diagnose and angiography becomes a useful diagnostic and therapeutic procedure in these patients. We present a case of a GIST located in the ileum which presented with a lower gastrointestinal bleeding (LGIB). The patient was stabilized by performing an arteriography and selective embolization of the bleeding point, followed by elective surgery.
Gastrointestinal stromal tumor (GIST) are rare with an incidence ranging between 12 cases - 15 cases per million people [
The gold standard in localized GIST is surgical excision whenever possible. Surgical treatment must achieve complete tumor resection (R0) since this is the most important prognostic factor [
A 49 year old woman with no previous medical history was admitted in our hospital with lower gastrointestinal bleeding. Physical examination revealed mucocutaneous pallor, tachycardia and hypotension. Abdominal examination was unremarkable and laboratory findings showed a haemoglobin level of 7.8 g/dL.
Gastroscopy was normal and colonoscopy reported a gastrointestinal bleeding from the small intestine. An abdominal CT scan was then performed revealing a 3 - 4 cm lesion in the ileum wall without active leak of contrast agent (
General anaesthesia was used and the patient was placed in the supine position with the legs spread apart (French position) and 20° reverse Trendelenburg. The surgeon stood between the legs and the first assistant on the left hand side of the patient. Pneumoperitoneum was established by an infra-umbilical open technique. Two more ports were placed in the right (10 mm - 12 mm) and left iliac quadrants (5 mm).
A small bowel resection was performed with careful handling to avoid tumor capsule rupture. The resected specimen of ileum which included the tumor was approximately 5 cm in length. A side to side isoperistaltic intracorporeal anastomosis was performed using a linear 60 mm stapler (ENDO GIA® Autosuture, Norwalk, CT) with an absorbable running suture to close the enterotomy. The specimen was extracted through the infra-umbilical port incision which was protected by a plastic-bag (
Operative time was 95 minutes and neither intraoperative nor postoperative transfusion was required. The patient was uneventfully discharged 4 days after surgery. Patient remains disease free at 15 month follow-up.
The histopathological study revealed a 3 cm diameter polypoid lesion without mucosal involvement. Microscopic findings showed a proliferation of monomorphic atypical spindle cells, with poorly defined cytoplasm, eosinophilic oval nucleus and nucleolus, focally evident fine chromatin, which are arranged in bundles in different directions. Resection margins were free of tumour infiltration. Tumour cells had a low proliferative index (Ki67 < 10%), with 1 mitosis per 50 high-power field (HPF). Immunohistochemistry showed positivity for C-Kit, CD34, SMA, vimentin, p53, MDM2, CD99, PGP 9'5, PDGRF-alpha and chromogranin. The tumor was classified as low risk according to the Miettinen classifycation.
The clinical manifestations of GIST depend on their size and location. Gastrointestinal tract bleeding is the most common presentation (50%), followed by abdominal pain (20% - 40%) and obstruction (20%). One third of them remain asymptomatic and are an incidental finding [2,6]. GI bleeding can be acute (melena, haematemesis or haemaotochezia) or chronic (anemia, fecal occult blood) and is caused by mucosal erosion.
Diagnosis of GIST depends on their location. For the upper gastrointestinal tract (oesophagus, stomach or duodenum) the method of choice is endoscopic ultrasonography (EUS) ± biopsy (EUS-FNA) [
Surgical resection is considered the treatment of choice in localized GIST.
An exception could be made in those tumours located in the esophagogastric junction or in the duodenum, less than 2 cm in size, where control and follow-up can be performed through endoscopic ultrasonography [
Special attention must be paid to avoid tumor rupture either spontaneously or during manipulation, which is associated with a higher risk of peritoneal spread and a worse prognosis [
Imatinib is currently approved for use as neoadjuvant therapy in patients where R0 resection does not seem feasible due to locoregional involvement and when an extended resection is not recommended [
The preoperative role of tumor embolization of active bleeding or for tumor shrinkage is unknown.
This case showed GIST can be safely resected through a minimally invasive approach, even in complicated presentations such as lower gastrointestinal bleeding. Angiographies studies can be helpful as a first step in manages of these tumors and complications. This could ensure better conditions for a subsequent laparoscopic resection.