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169 GASTROINTESTINAL STROMAL TUMOUR (GIST): THE ROLE OF UPPER ENDOSCOPY IN THE INITIAL MANAGEMENT OF GASTROINTESTINAL BLEEDING J Cheung, C De Gara, B Balachandra, A Kumar, CKY Wong GISTs can present with varied clinical manifestations, such as gastrointestinal bleeding. The role of the endoscopist can be important in the initial diagnosis and management of this lesion.
University of Alberta, Edmonton, Alberta
We describe and present a combination of endoscopic, radiologic, intra-operative, pathologic, and histologic images of a case of a 37 year old male who presented with a massive upper gastrointestinal (UGI) bleed due to a GIST. An esophagogastroduodenal endoscopy was initially normal; however further insertion of the gastroscope down to the maximum distance of 100cm revealed a protruding lesion. In the fourth part of the duodenum was a 1.5cm protruding submucosal lesion with central ulceration and erythema. India Ink was applied to mark the lesion. The patient subsequently rebled in hospital and a pediatric colonoscope was used to perform esophagogastroduoduodenal endoscopy. The duodenal submucosal lesion was easily located and now showed superficial ulceration with oozing. 2 resolution endoclips were placed with good hemostasis effect and there was no further bleeding to the time of surgery, 9 days later. A laparotomy was performed and immediate localization of the tumour was obtained by visualization of India Ink and palpation of the endoclips. The tumour was resected and gross pathologic specimen revealed a 1.4cm exophytic mass with hemorrhage on the surface and no serosal penetration. Histologic examination diagnosed the presence of an undifferentiated GIST with the hallmark CD 177 Antigen positivity. The GIST was low risk category based on the absence of vascular and lymphatic invasion, size <5cm, and <5 mitotic figures per 50x high power field. The patient recovered well post-operatively and will receive continued oncologic surveillance.
This case demonstrates that GISTs are a rare cause of UGI bleeding. These lesions may be just distal to the reach of a regular gastroscope and enteroscopy should be considered in patients with significant UGI bleeding of unknown cause. Endoscopy is an important tool in the initial management; assisting with not only diagnosis, but also mapping. To our knowledge, this is the first reported case of GIST hemostasis using endoclips.