Hospital: Hospital de 12 Octubre.
Aut@r o Autores: A. Merina, D. Plata, M. Castaño, V. Gonzalez, V.S. Geronimo Aguilar, J. Zulae.
A 56-year-old man presented at the emergency department with subacute abdominal pain, repeated vomiting and constipation. The pain was diffuse, colicky and had started 24 hours ago. Four months ago, he had been admitted to our hospital with melena and anemia attributed to a gastric ulcer. On physical examination, the abdomen was distended and there were few stools in the rectum. No palpable masses, rebound or guarding were found. Abdominal radiographs revealed dilated small bowel loops with air-fluid levels consistent with obstruction. A contrast-enhanced computed tomography was then performed and small bowel obstruction was confirmed. The obstruction seemed to be caused by an ileal focal wall thickening associated with a large pelvic mass. There were mild ascites and normal bowel walls enhancement. There was no adenopathy.
The diagnosis was small bowel obstruction secondary to an ileal gastrointestinal stromal tumor (GIST), as suggested in the report. No signs of ischemia were present. The patient underwent an intestinal resection that included the tumor and the patient recovered without complications. GIST accounts for only 2% of gastrointestinal tumors. The most common symptoms are those related to gastrointestinal bleeding due to the tendency of GIST to produce mucosal ulceration. Only around 3%-15% of cases present with acute abdominal symptoms which is more frequent in jejunal and ileal GIST, as was our case. The key diagnostic findings were the bowel wall thickening where arised a large, well circumscribed, lobulated, pelvic mass with tortuous vessels, along with the absence of lymphadenopathies. It is essential to provide an accurate report when GIST is suspected as the radiological diagnosis can contribute to improving the prognosis of the patient because the elective treatment is surgical resection with clear margins and during the intervention, it is crucial that the capsule remains unbroken therefore the surgeon must be aware of the possible diagnosis. Besides, tumor location and size, jointly with the mitotic activity will determine the estimated risk of tumor progression and metastases. Afterwards, that risk estimation will establish the need for treatment with imatinib, which has proven to increase the average survival from 15 to 55 months.
When a GIST presents as a bowel obstruction, it is not “just an obstruction”. We must recognize the characteristics of this tumor and we should be aware of the relevance of the radiological report.
- Caterino S, Lorenzon L, Petrucciani N, et al, “Gastrointestinal stromal tumors: correlation between symptoms at presentation, tumor location and prognostic factors in 47 consecutive patients» World J Surg Oncol, 2011 feb 1, 9:13. - Zhou C, Duan X, Zhan