S3378 Bleeding GIST Treated Successfully With Hemospray in a Patient With Neurofibromatosis Type 1

Abstract

Introduction: Gastrointestinal stromal tumors (GISTs) are rare subepithelial mesenchymal neoplasms of the gastrointestinal tract that are typically KIT (CD117) positive. GISTs can present with a wide range of symptoms including gastrointestinal hemorrhage. Small bowel bleeding from a GIST can be difficult to treat endoscopically and there is a paucity of data on the use of TC-325 (hemospray) for these tumors. Case Description/Methods: A 47-year-old man with a past medical history significant for neurofibromatosis type 1 and multifocal small bowel GISTs presented to our center with symptomatic anemia. The patient described previous episodes of melena. The patient's initial hemoglobin was 2.2 g/dl. He was initially treated with a transfusion of 4 units packed red blood cells. CT abdomen and pelvis with IV contrast was obtained which revealed a centrally located 6 x 5cm small bowel mass with heterogeneous enhancement and intraluminal signal concerning for active gastrointestinal hemorrhage. A push enteroscopy was performed using a pediatric colonoscope via the mouth and advanced deeply into the small bowel. A large ulcerated submucosal mass with active bleeding was found at the junction of the fourth portion of the duodenum and proximal jejunum. Submucosal injection of 1:10,000 diluted epinephrine around the ulcer base failed to achieve hemostasis. Next, the hemospray catheter was advanced to several centimeters proximal to the bleeding ulcer. Hemospray was deployed and immediate hemostasis was achieved after coating the area. Discussion: The majority of GISTs are sporadic and found in the stomach. Patients with neurofibromatosis type 1 however, have a higher incidence of GISTs, are often multifocal, and most commonly are found in the small intestine as demonstrated here. Endoscopic treatment of small bowel tumor bleeding is challenging because of the location and nature of the bleeding. Conventional treatments such a hemoclips or bipolar electrocautery usually fail to stop tumor bleeding. TC-325 or hemospray is a novel inert powder which accelerates the coagulation cascade leading to rapid hemostasis of actively bleeding lesions. Hemospray should be considered first line treatment for malignant bleeding because of its ease of use, wide field of application and demonstrated success.