Case Report

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: nisarahmedmd@yahoo.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 differentiation^2,4,8.

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 GIT^6,7. 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 tumor^5,8. Due to a mutation in the c-kit proto-oncogene in 85% of cases which is a tyrosine kinase^12,13, in PDGFRA in 10% of cases or rarely PRAF kinase mutation^4,5,6,9,11. 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 mesylate^3,6,7,9,11. 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.

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