UNUSUAL PRESENTATION OF GASTROINTESTINAL STROMAL TUMORS
Tania Torres*, Jairo A. Espinosa, Saad Shebrain
Surgery, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI
INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are common tumors of the gastrointestinal tract that derive from malignant precursors of the interstitial cells of Cajal affecting mostly middle aged to elderly patients. GIST's are most commonly found within the stomach in 60-70% of patient, while 25-35% are located in the small intestine. Based on our literature review, this is the first description of a GIST presenting as a perforated diverticular structure within the terminal ileum
CASE PRESENTATION:
We present the case of a 50- year-old female with no significant medical history who initially presented to an urgent care center for one day history of acute abdominal pain associated with nausea and emesis. An upright chest x-ray and abdominal x-ray demonstrated a free air under the diaphragm. The patient was transferred to the emergency department (ED).
In the ED, the patient vital signs were notable for tachycardia to the 110's bpm and systolic blood pressures of low 100's. Abdominal examination demonstrated diffuse tenderness more pronounced in the right side of the abdomen, right upper quadrant and epigastric region concerning for perforated viscus. Fluid resuscitation and parenteral antibiotics were started, and the patient was taken emergently to the operating room. A diagnostic laparoscopy was performed and demonstrated a significant inflammation and contamination in the right side of the abdomen and pelvis secondary to perforated small bowel diverticulum, in the mesenteric side, 100 cm proximal to the cecum. Once the contamination was controlled, a segmental small bowel resection, with adjacent mesentery, with side-to-side functional end-to-end anastomosis was performed. Pathology of the resected specimen showed a perforated small bowel diverticulum with a 2.7 x 2.5 cm gastrointestinal stromal tumor (GIST).
DISCUSSION: Most of gastrointestinal stromal tumors (GISTs) are asymptomatic and usually found incidentally during endoscopic or surgical procedures. When symptomatic, these tumors usually present with an upper or lower GI bleeding, abdominal pain, or obstructive symptoms. This case illustrates a rare presentation of a GIST as a perforated diverticular structure of small bowel
CONCLUSION:
The patient did well post-operatively. She was discharged home on post-operative day 5. At 4 months follow up, the patient is doing well. An upper GI endoscopy was performed and showed no evidence of gastric or duodenal abnormalities suggestive of GIST.
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