Massive Bleeding after Endoscopic Biopsy from Jejunal GI Stromal Tumor

Abstract

Purpose: Gastrointestinal stromal tumors (GIST) are considered a rare cause of GI bleeding. In the small bowel they are most commonly seen in the jejunum followed by the ileum and duodenum. Significant bleeding can happen due to these tumors. We are reporting a case of massive GI bleed that ensued after taking an endoscopic pinch biopsy from a jejunal GIST. The patient was 43 year old Asian female presenting with microcytic anemia, hemoglobin of 4.9 g/dl and ferritin of 5 mg/dl. Fecal occult blood test was positive but no overt GI bleed was documented. On pushing the gastroscope just beyond the duodenum into the proximal jejunum a large irregular subepithelial bulge was seen with a small overlying ulcer. After the first attempt to take a biopsy, the lesion started to bleed massively obliterating the endoscopic view. Soon after that the patient developed hypotension leading to hypovolemic shock and cardiac arrest. Efforts were successful in resorting her vital signs and then she was rushed for laparotomy revealing a 9 cm mass in the first portion of the jejunum. Histologic examination of the resected mass showed spindle cell tumor with positive CD 117 staining consistent with GIST. Small bowel GIST could present with massive obscure GI bleeding. Push enteroscopy, double balloon enteroscopy as well as capsule endoscopy were all reported to aid in localization of such tumors. However, tissue diagnosis is difficult since endoscopic biopsies do not have a high yield for the deeper subepithelial layers even when using the bite-on-bite technique. Endoscopic ultrasound (EUS) has been valuable in obtaining diagnostic information based on morphologic determination of the layer of tumor origin and through tissue acquisition using FNA. Nevertheless, EUS has limited applicability in the small bowel location. Other common imaging modalities like CT scan and MRI can be helpful in localizing large tumors but with low specificity to the histologic diagnosis. In many instances patients will eventually require laparoscopy or laparotomy for both diagnostic and therapeutic purposes. The safety of endoscopic pinch biopsy is well established even in patients on anticoagulation. It is a common practice to take endoscopic pinch biopsies from subepithelial lesions despite the low yield. In our case massive life threatening bleeding developed after the first biopsy of a jejunal GIST. To avoid uncontrollable bleeding it would be reasonable to forgo biopsying symptomatic subepithelial lesions suspected to be GIST in the small bowel, especially if that is not expected to change the need for surgical resection.