Gastrointestinal Stromal Tumor

Abstract

Case An 86 year old male presented to the ER with a 1 day history of coffee ground emesis, weakness and nausea. Pertinent medication use included daily aspirin and occasional NSAIDs. The patient remained hemodynamically stable in the ER, but the nasogastric lavage showed bloody return that did not clear. Urgent EGD was performed and a large adherent clot in the fundus was visualized. The patient was transferred to the ICU for monitoring. The next day, melena with hypotension occurred with a 4gm drop in hemoglobin. Repeat EGD was performed revealing a 7mm umbilicated submucosal mass in the gastric fundus, 1cm from the gastroesophageal junction with stigmata of recent bleeding. An upper endoscopic ultrasound was performed and revealed a mass lesion in the gastric cardia originating from within the muscularis propria. The mass was hypoechoic with well-defined borders, consistent with the ultrasonographic diagnosis of gastrointestinal stromal tumor (GIST). Endoscopic submucosal resection was not attempted due to bleeding risk. The patient and family refused surgical intervention. Instead, angiographic embolization of the left gastric artery branch supplying the GIST was successfully performed. The patient had no additional bleeding, resumed a normal diet and was discharged 3 days later. Discussion: GIST are defined as mesenchymal tumors arising from the GI wall, mesentery, omentum or retroperitoneum. GIST were initially thought to represent smooth muscle tumors of the GI tract. They were formerly classified as leiomyomas and leioimyosarcomas. It is now proposed that GIST originates from the Interstitial cells of Cagal (ICC) or may evolve from pluripotential stem cells that differentiate toward a pacemaker cell phenotype. The true incidence of GIST is unknown. Unconfirmed estimates of the annual incidence in the U.S. are about 5000 to 6000 cases/year. The majority of GIST occurs in the stomach (60–70%). When in the stomach, GIST are associated with UGIB, abdominal pain or a palpable mass. Embolization for GIST to control UGIB has only been reported once in the literature previously. At that time, it was used to control bleeding and limit the extent of planned surgical resection. This case is the 2nd to use this method to control UGIB in a case of GIST and the 1st to control recurrent bleeding associated with GIST. This may impact clinical management of GIST upon endoscopic discovery without active bleeding.