Sanjay Prasad, MD1, Eric Smith, MD2, Tyler Tepfenhart, DO1, Manuel Garza, MD, MS2, Rajiv Srinivasa, MD2, Andrew Horton, DO3, Chiranjeevi Gadiparthi, MD4 1Baylor Scott & White Medical Center, Georgetown, TX; 2Baylor Scott & White Medical Center, Round Rock, TX; 3Baylor Scott & White Medical Center, Temple, TX; 4Baylor Scott and White, Round Rock, TX
Introduction: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasm of the gastrointestinal (GI) tract, with 30% of cases occurring in the small bowel. We present a patient with an acute lower GI bleed, found to be due to a GIST in the mid-jejunum.
Case Description/Methods: A 29-year-old male with chronic constipation presented with left lower quadrant abdominal pain and multiple recent episodes of melena and hematochezia, with associated dizziness and dyspnea. He had a heart rate of 157 bpm and a blood pressure of 94/33 mm Hg. Conjunctival pallor and left lower quadrant abdominal tenderness were present on exam. Labs showed a hemoglobin of 7.9 g/dL from 13.6 g/dL the day prior and a lactic acid of 2.1 mmol/L. A CT scan revealed an oval-lobulated mass within the lower mesentery. Subsequent esophagogastroduodenoscopy was unremarkable and colonoscopy revealed a large amount of maroon blood throughout the colon with blood clots visualized in the ascending colon and cecum, though no source of bleeding was visualized. The patient received a blood transfusion and underwent a mesenteric angiography with successful particle embolization of a bleeding hyper-vascular jejunal mass with interventional radiology. He was transferred for surgical oncology and underwent small bowel resection of a 3.1 cm mass in the mid-jejunum. The pathology revealed a grade G1 GIST (spindle cell type). The patient had resolution of his symptoms following the procedure.
Discussion: GISTs are mesenchymal tumors with predominantly smooth muscle differentiation and originate from the interstitial cells of Cajal due to mutations in the KIT tyrosine kinase gene in most cases. While 64% of small bowel GISTs present with bleeding (1), they can also present as palpable masses, perforation, obstruction, or incidental findings on imaging. Hematochezia is the most common presentation of a bleeding jejunal GIST, though hematemesis can also occur. CT angiography is used to identify bleeding lesions, as jejunal lesions can be difficult to access endoscopically. Though rare, small bowel GISTS should be considered in the differential diagnoses for patients with no clear source of lower GI bleeding. Reference: (1) Daldoul S, Moussi A, Triki W, Baraket RB, Zaouche A. Jejunal GIST causing acute massive gastrointestinal bleeding: role of multidetector row helical CT in the preoperative diagnosis and management. Arab J Gastroenterol. 2012 Sep;13(3):153-7.
Figure: A) Clots visualized in the ascending colon on colonoscopy
B) Blood visualized in the cecum on colonoscopy
C) GIST, spindle cells, 100X: Elongated nuclei with eosinophilic cytoplasm and minimal pleomorphism
D) GIST, CD117 staining, 100X: The tumor had diffuse cytoplasmic staining for CD117. Staining for CD117 is positive in 95% of GISTs
E) GIST, DOG1 staining, 100X: The tumor had diffuse cytoplasmic staining for DOG1. DOG1 is the most sensitive and specific marker for GISTs
F) Superior mesenteric arteriogram demonstrates a hyper-vascular jejunal mass in the left mid abdomen
G) Super selective jejunal arteriogram prior to embolization demonstrates the jejunal arterial supply to the mass. Particle embolization was performed of the mass at this location
H) Superior mesenteric arteriogram following particle embolization demonstrates complete devascularization of the jejunal mass in the left mid abdomen
I) Surgical pathology specimen from resection
Disclosures:
Sanjay Prasad indicated no relevant financial relationships.
Eric Smith indicated no relevant financial relationships.
Tyler Tepfenhart indicated no relevant financial relationships.
Manuel Garza indicated no relevant financial relationships.
Rajiv Srinivasa indicated no relevant financial relationships.
Andrew Horton indicated no relevant financial relationships.
Chiranjeevi Gadiparthi indicated no relevant financial relationships.
Sanjay Prasad, MD1, Eric Smith, MD2, Tyler Tepfenhart, DO1, Manuel Garza, MD, MS2, Rajiv Srinivasa, MD2, Andrew Horton, DO3, Chiranjeevi Gadiparthi, MD4. P4205 - Getting to the GIST of the Acute Lower Gastrointestinal Bleed, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
