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CASE REPORT Table of Contents   
Year : 2002  |  Volume : 12  |  Issue : 1  |  Page : 99-101
Transcatheter embolisation of jejunal stromal tumour presenting with haematochezia


Department of Radiology and Imaging, Northwest Armed Force Hospital, PO Box 100, Tabuk, Saudi Arabia

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Keywords: Angiography, Gastrointestinal tumours, Transcatheter arterial embolisation

How to cite this article:
Shahat A H, Obaideen A M, Pandey U C. Transcatheter embolisation of jejunal stromal tumour presenting with haematochezia. Indian J Radiol Imaging 2002;12:99-101

How to cite this URL:
Shahat A H, Obaideen A M, Pandey U C. Transcatheter embolisation of jejunal stromal tumour presenting with haematochezia. Indian J Radiol Imaging [serial online] 2002 [cited 2019 Jul 24];12:99-101. Available from: http://www.ijri.org/text.asp?2002/12/1/99/28429

   Introduction Top


Gastrointestinal stromal tumours (GIST) are stromal tumours of the gastrointestinal tract diagnosed by immunohistochemistry. The tumour originates from the muscular components of the stromal layer, and majority of GISTs are located in the stomach and small intestine [1].

GIST in the jejunum may present with malena but it is rare for these tumours to present with rectal bleeding or haematochezia [2],[3]. Herein we present a case of jejunal stromal tumour presenting with massive rectal bleeding, which was angiographically embolised and subsequently resected at elective operation.


   Case report Top


A 23-year-old man was sent to the Emergency Room after passing blood in his stools for the previous two days. Physical examination revealed a young man with tachycardia (pulse 110/min) and blood pressure of 124/50 mmHg. Nasogastric lavage showed no evidence of upper gastrointestinal bleeding. Rectal examination revealed a few blood clots and black stool. Routine blood examination showed anaemia (haemoglobin 8.6 g/dl). An emergency upper gastrointestinal endoscopy did not reveal any significant pathology. Blood transfusion with four units of packed red cells was administered. An additional six units of packed red cells were infused over 24 hours. The patient continued to have rectal bleeding, he did not show improvement and the haemoglobin level dropped to 8.1 g/dl on the second day of hospitalization. A colonoscopy disclosed massive blood clots in the large bowel up to the caecum but it failed to locate the source of bleeding. Angiography was performed on the second day. A superior mesenteric angiogram revealed a hypervascular tumour showing numerous abnormal vessels, unusual sustained blush within the tumour and prominent draining veins [Figure1]a & b. A super selective arteriogram showed that this tumour was supplied by one jejunal branch of the superior mesenteric artery [Figure - 2]. Transcatheter embolisation of this artery and its branches was done by sterile absorbable gelatin sponge pledglets (1-2 mm in size) mixed in a solution of water-soluble contrast and saline. Embolisation was done under fluoroscopic control and stopped when all of the abnormal vessels were obliterated [Figure - 3].

The patient was closely monitored for 24 hours. He developed mild abdominal pain and leukocytosis but responded well to symptomatic treatment. There was no drop in haemoglobin in the subsequent 24 hours (haemoglobin 9.4 g/dl). A CT examination of the abdomen was performed after angiography, which revealed a well-marginated soft tissue density mass in relation to the distal jejunum. There was no evidence of abdominal lymphadenopathy or metastatic deposits in the liver. The patient was taken for elective surgery after three days. Laparotomy revealed a mass in the distal jejunum along its ante-mesenteric border, which was firm, and appeared congested with a few superficial areas of necrosis. A segment of the jejunum containing the tumour was resected and healthy jejunal margins were joined by side-to-side anastomosis.

The pathological specimen disclosed a solid mass measuring 7.5 cm in greatest diameter attached to the jejunum. The overlying mucosa and resected margins were grossly unremarkable. Sections of the mass showed a homogenous grey tan interior cut surface with 2 cm diameter cystic area. Tumour cells exhibited strong immunoreactivity against vimentin, S-100 protein, myoglobin and neurone specific enolase. The cells stained positive for CD34 with no evidence of mitotic activity.


   Discussion Top


GIST is increasingly recognized as a distinct entity within soft tissue tumours. A tumour in the small intestine may present with malena and anaemia but it rarely presents with haematochezia requiring urgent management [2],[4]. GISTs occur throughout the gastrointestinal tract but are most common in the stomach and small intestine. They differ histologically, immunochemically and genetically from typical leiomyomas that are negative for C-kit and CD34. Evaluation of malignancy of GISTs is based on mitotic count, tumour size and extra gastrointestinal spread [1],[3].

Radiologically, GISTs resemble soft tissue tumours of the intestinal wall and can be detected by ultrasound or CT, and a guided biopsy can be done to obtain the tissue diagnosis [4],[5].

Angiography is generally not required to obtain a diagnosis. A previously asymptomatic tumour may be encountered during angiography when it is performed for the management of intestinal bleeding [4]. Angiographic findings in our case were similar to leiomyoma described previously, and consisted of a hypervascular tumour with many early filling abnormal vessels, unusually sustained tumour blush and prominent draining veins [4],[5]. Extravasation of contrast depends upon the rate of bleeding from the eroded vessels at the time of angiography. Selective arteriography and transcatheter embolisation have been advocated in the management of acute gastrointestinal haemorrhage [6],[7]. Proper placement of catheter in selected artery, placing of the catheter as close to the lesion as possible by superselective catheterization and deliberate injection of strips of gel foam under fluoroscopic control are essential to avoid necrosis of the adjacent normal bowel loops [7],[8].

Our patient is a rare case of jejunal GIST presenting with haematochezia requiring blood transfusions for maintenance of suitable haemodynamics. Intra-arterial embolotherapy was successfully used for stopping the haemorrhage from the tumour vessels and succeeded in stabilizing the patient's condition for elective surgery.

In conclusion, jejunal GIST is a rare cause of rectal bleeding. Emergency angiography is useful to detect the site and cause of bleeding. Transcatheter embolisation helps in management and provides better conditions for elective surgery.

 
   References Top

1.Miettinen M, Sarlomo-Rikala M and Lasota J. Gastrointestinal Stromal Tumours. Ann Chir Gynaecol 1998; 87 (4): 278-81.  Back to cited text no. 1    
2.Bagnolo F, Bonassi U, Scelsi R and Testoni PA. Gastric Stromal Tumour: A Rare Neoplasm Presenting with Gastrointestinal Bleeding. Eur J Gastroenterol Hepatol 1998; 10 (9): 791-794.  Back to cited text no. 2    
3.Wong LS, Rusby J, Bassi UA, Rowlands D, Ismail T. Stromal Tumour of the Small Bowel J R Soc Med 2000; 93 (3): 145-146.  Back to cited text no. 3    
4.Chen C.Y., Lu C.L., LO S.S., Yu I.T., Chang F.Y., Lee S.D. Case Report: Life Threatening Haematochezia from a Jejunal Leiomyoma. J Gastroenterol Hepatol 1997; 12: 382-384.  Back to cited text no. 4    
5.Fields S, Libson E. Computerised Tomography Guided Aspiration Care Needle Biopsy of Gastrointestinal Wall Lesions. J Comput AssistTomogr 2000; 24: 224-228.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Leitman IM, Paull DE, Shires GT. Evaluation & Management of Massive Lower Gastrointestinal Hemorrhage. Ann. Surg. 1989; 209: 175-180.  Back to cited text no. 6    
7.Chalmers AG, Robinson PJ, Chapman AH. Embolisation in Small Bowel Haemorrhage. Clin Radiol 1986; 37: 379-81.  Back to cited text no. 7  [PUBMED]  
8.Rosenkrantz H, Bookstein JJ, Rosen RJ, Goff WB, Heely JF. Postembolic Colonic Infarction. Radiology 1982; 142: 47-51.  Back to cited text no. 8    

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Correspondence Address:
A H Shahat
Department of Radiology and Imaging, Northwest Armed Force Hospital, PO Box 100, Tabuk
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]



 

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