Small Bowel Bleeding due to GIST

Single balloon enteroscopy was negative, however only part of the terminal ileum could be visualized. CT of the abdomen showed a huge pelvic mass originating or infiltrating the small bowel. This tumor was G3M3 based on the classification by Martinez-Alcala et al (1). Percutaneous, CT guided biopsy revealed an epithelioid gastrointestinal stromal tumor.

Classification of Small Bowel GIST (Reference No. 1)

Gastrointestinal stromal tumors (GIST) are mesenchymal neoplasms that arise from the cells of Cajal in the gastrointestinal tract (1). While most GISTs are located in the stomach, 30 % of GISTs are found in the small bowel. Small-bowel GISTs tend to be more aggressive and have worse prognosis with a 5-year survival rate of 25 % (2). Therefore, an early diagnosis is mandatory. Patients with GIST usually present with obscure gastrointestinal bleeding, which results from a surface ulceration and necrosis (3,4). Other complications of GISTs include bowel obstruction, intussusception, and tumor perforation (1-4). The diagnosis of small bowel GIST can be very difficult. Because of its non-specific initial symptoms, patients are often diagnosed with a small bowel GIST only in advanced, metastasized stages of the disease, when curative therapeutic option is not possible. Whenever investigating patients with obscure gastrointestinal bleeding and non-conclusive endoscopic examinations such as EGD and colonoscopy, deep enteroscopy and capsule endoscopy, it is important to obtain a computed tomography of the abdomen to exclude masses, cancers, neuroendocrine tumors (carcinoid) and GIST, such as in this case.

References

Martinez-Alcalá A, Fry LC, Kröner T, Peter S, Contreras C, Mönkemüller K. Endoscopic spectrum and practical classification of small bowel gastrointestinal stromal tumors (GISTs) detected during double-balloon enteroscopy. Endosc Int Open. 2021 Apr;9(4):E507-E512. doi: 10.1055/a-1341-0404. Epub 2021 Mar 17. PMID: 33816770; PMCID: PMC7969139.

Mullady D K, Tan B R. A multidisciplinary approach to the diagnosis and treatment of gastrointestinal stromal tumor. J Clin Gastroenterol. 2013;47:578–585. doi: 10.1097/MCG.0b013e3182936c87

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