J Med Discov (2017); 2(3):jmd17024; DOI:10.24262/jmd.2.3.17024; Received June 9th,2017, Revised July 22nd,2017, Accepted August 13th,2017, Published August 20th, 2017.
Surprise Finding in a Healthy Male with First GI Bleeding
Saba Abdulsada1, Mohammed Al Azzawi1, Nisar Ahmed1,*
1Department of Gastroenterology, Park Plaza Hospital, Houston, TX 77004 USA
* Correspondence: Dr. Nisar Ahmed, M.D. F.A.C.G. , Chief of Gastroenterology, Park Plaza Hospital, Houston, TX 77004, USA. Email: email@example.com.
Advances in the identification of gastrointestinal stromal tumors(GIST), its molecular and immunohiostochemical basis, and its management have occurred over the last two decades1. Mazur and Clarke used the term GIST in 1983 for a distinct set of mesenchymal tumors of the Gastrointestinal tract(GIT)10 having no ultra-structural or immunohistochemical features characteristic of smooth muscle differentiation2,4,8.
Gastrointestinal Stromal Tumor (GIST) is the most common mesenchymal, not epithelial, tumor of the gastrointestinal tract (GIT)4,11,12,13. It occurs most commonly in the stomach or small intestine but can occur anywhere in the GIT6,7. It can cause bleeding, abdominal pain and early satiety5. We reported a totally asymptomatic male who went to the emergency department (ED) of a nearby hospital complaining of passing massive tarry stool. Initial investigation revealed GIST tumor.
A 59 year old white male patient, who works on an offshore oil rig, complained of severe melena. He went to a nearby mainland hospital. He was evaluated in the ED. Physical examination was essentially normal apart from pallor. His lab test showed Hb: 9g/dl, positive stool occult blood test. He was referred for an upper GIT endoscopy. Esophagogastroduodenoscopy (EGD) showed a large mass 5cm in diameter hanging from the stomach fundus (Fig. 1); with a big ulcer on its surface. Endoscopic biopsies were sent for histopathological evaluation and showed only evidence of gastritis. He was referred to a surgeon for operative management. Surgical histopathology showed it was a GIST tumor (Fig. 2).
GIST is a tumor of the GIT smooth muscle pace maker cells “interstitial Cell of Cajal” so it is a sub mucosal tumor5,8. Due to a mutation in the c-kit proto-oncogene in 85% of cases which is a tyrosine kinase12,13, in PDGFRA in 10% of cases or rarely PRAF kinase mutation4,5,6,9,11. Overall GIT tumors, GIST is accounting for only 1-3%. Discovery of c-kit mutations has led to the development of molecular therapy using tyrosine kinase inhibitors, like imatinib mesylate3,6,7,9,11. The prognosis is dependent on the size of tumor and the number of mitotic figures per high power field5.
Figure 1. GIST Gastric Fundus 6*4.5*5 cm.
Figure 2. show spindle cell type (a) CD117 & CD34 Immunostains strongly positive(b).
GIST should be included in the differential diagnosis of upper GIT bleeding. Although relatively rare, it can be the cause of massive melena. Early diagnosis and proper management can decrease the morbidity and mortality.
Conflict of interest
1.Palankezhe Sashidharan, Apoorva Matele, Usha Matele, Nowfel Al Felahi, and Khalid F. Kassem, “Gastrointestinal Stromal Tumors’’case repport,Oman Medical Journal, 2014 Mar; 29(2): 138–141.
2.Mazur MT, Clark HB. Gastric Stromal Tumors: Reappraisal of Histogenesis. Am J Surg Pathol 1983:7509-7519.
3.de Matteo RP, Ballman KV, Antonescu CR et al., Adjuvant imatinib mesylate after resection of localised, primary gastrointestinal stromal tumor: a randomised, double-blind, placebo-controlled trial,” The Lancet, vol. 373, no. 9669, pp. 1097–1104, 2009.
4.Laurini JA and Carter JE. Gastrointestinal stromal tumors: a review of the literature. Archives of Pathology and Laboratory Medicine, vol. 134, no. 1, pp. 134–141, 2010.
5.Patil DT and Rubin BP. Gastrointestinal stromal tumor: advances in diagnosis and management. Archives of Pathology and Laboratory Medicine, vol. 135, no. 10, pp. 1298–1310, 2011.
6.Demetri GD, von Mehren M, Antonescu CR et al., NCCN task force report: Update on the management of patients with gastrointestinal stromal tumors. JNCCN Journal of the National Comprehensive Cancer Network, vol. 8, supplement 2, pp. S1–S44, 2010.
7.Chandramohan K, Agarwal M, Gurjar G et al., Gastrointestinal stromal tumour in Meckel’s diverticulum. World Journal of Surgical Oncology, vol. 5, p. 50, 2007.
8.Demetri GD, Titton RL, Ryan DP, and Fletcher CD. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 32-2004. A 68-year-old man with a large retroperitoneal mass. The New England Journal of Medicine, vol. 351, no. 17, pp. 1779–1787, 2004.
9.Terada T. Gastrointestinal stromal tumor of the uterus: a case report with genetic analyses of c-kit and PDGFRA genes. International Journal of Gynecological Pathology, vol. 28, no. 1, pp. 29–34, 2009.
10.Laperouse P, Raines D, Diamond K et al., Gastrointestinal stromal tumors: a case report and review of the literature. The Journal of the Louisiana State Medical Society, vol. 160, no. 3, pp. 128–134, 2008.
11. Lasota J, Jasinski M, Sarlomo-Rikala M, and Miettinen M. Mutations in exon 11 of c-kit occur preferentially in malignant versus benign gastrointestinal stromal tumors and do not occur in leiomyomas or leiomyosarcomas. American Journal of Pathology, vol. 154, no. 1, pp. 53–60, 1999.
12. Wardelmann E, Losen I, Hans V et al., Deletion of Trp-557 and Lys-558 in the juxtamembrane domain of the c-kit protooncogene is associated with metastatic behavior of gastrointestinal stromal tumors. International Journal of Cancer, vol. 106, no. 6, pp. 887–895, 2003.
13. Lux ML, Rubin BP, Biase TL et al., KIT extracellular and kinase domain mutations in gastrointestinal stromal tumors. American Journal of Pathology, vol. 156, no. 3, pp. 791–795, 2000.
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