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 17 October 2017

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Cody B Barnett, Kressida Cain and Rayburn F Rego An unusual case of hematemesis: gastrointestinal stromal tumor
Cody B Barnett, Kressida Cain and Rayburn F Rego, 01 May 2005
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Summary

The following case involves a young patient with an ulcerated gastrointestinal stromal tumor (GIST) causing hematemesis. This is an unusual case as GIST is not a common cause of hematemesis, and GISTs are typically found in middle-aged and older people.

History

A 27-year-old woman presented with the sudden onset of hematemesis while at work. She had experienced early satiety for 6 months and reported a prior history of non-steroidal anti-inflammatory drug use. Nasogastric aspirate demonstrated dark red blood with clots. She gave no history of weight loss.

Examination

Examination revealed a thin young female with orthostatic vital signs. No abdominal tenderness or masses palpable. She had heme positive brown stool on rectal exam.

Investigation, management and outcome

Initial hemoglobin and hematocrit were 11g/dl and 32% respectively. Upper endoscopy performed in the emergency department revealed a large mass in the body of stomach (Figures 1 and 2). The mass had smooth overlying mucosa with ulcerations. CT demonstrated the mass with no other lesions.

Figure 1

Figure 2

She subsequently went to surgery and a 6.5 x 4 x 3.7cm mass was completely resected. Pathology revealed a mesenchymal neoplasm composed of cellular bundles of spindle-type cells. There was no necrosis. Very rare mitotic figures were present, less than 5 per 50 HPF. Immunohistochemical stains were positive for CD117 and CD34. The findings were diagnostic for GIST (Figure 3).

Figure 3

Discussion

GISTs are defined as mesenchymal tumors arising from the gastrointestinal wall, mesentery, omentum, or retroperitoneum that express the c-kit proto-oncogene, a cell membrane receptor with tyrosine kinase activity. The expression of c-kit distinguishes GISTs from true leiomyomas, leiomyosarcomas, and other mesenchymal tumors of the gastrointestinal tract [1, 2, 5].

Unlike in this case, GISTs predominantly present in middle-aged and people, with no significant difference between distribution in males and females. Most GISTs arise from the stomach (50-70%) and small intestine (20-30%). Symptoms depend on the tumor size and location and are usually non-specific. The most common complication is bleeding (40-50%) [2].

The determination of malignancy in GISTs is difficult and cannot be resolved with use of histopathological features alone. The National Institute of Health instituted guidelines in 2001 that based relative risk of malignancy on tumor size and mitotic count [1,3,4].

This case was first published on GastroHep.com in 2005.

Authors

Dr Cody B Barnett, MD
Dr Kressida Cain, MD
Dr Rayburn F Rego, MD
University of South Alabama, Departments of Gastroenterology and Pathology, Mobile, Alabama, USA

Contact information

Dr Cody B. Barnett
University of South Alabama, Departments of Gastroenterology and Pathology, Mobile, Alabama, USA
cbarnett@usouthal.edu

References

  1. Davila RE, Faigel DO. GI stromal tumors. Gastrointest Endosc 2003; 58: 80-8.

  2. Rossi CR, Mocellin S, Mencarelli R, et al. Gastrointestinal stromal tumors: from a surgical to a molecular approach. Int J Cancer 2003; 107: 171-6.

  3. Miettinen M, Lasota J. Gastrointestinal stromal tumors - definition, clinical histological, immunohistochemical, and molecular genetic features and differential diagnosis. Virchows Arch 2001; 438: 1-12.

  4. Samiian L, Weaver M, Velanovich V. Evaluation of gastrointestinal stromal tumors for recurrence rates and patterns of long-term follow-up. Am Surg 2004; 70: 187-92.

  5. Hwang JH, Kimmey MB. The incidental upper gastrointestinal subepithelial mass. Gastroenterology 2004; 126: 301-7.

This article was first published on GastroHep in 2005.

 
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