Clinical Case Study
LeAnne Vitito, MS, RN, CGRN, APRN Department Editor
A RARE CAUSE OF GASTROINTESTINAL BLEEDING IN A YOUNG FEMALE: JEJUNAL GASTROINTESTINAL STROMAL TUMOR Hakan Bulus, MD Adnan Tas, MD Ahmet Koyuncu, MD
G
THE OFFICIAL JOURNAL OF THE SOCIETY
astrointestinal stromal tumor (GIST) was first described by Mazur and Clark (1983) in 1983, as a rare oncologic entity derived from cajal progenitor cells (Nishida et al., 1998). The GIST is among the rare tumors composing 1% of all gastrointestinal (GI) tumors and is most often seen in the stomach (60%–70%) (Miettinen & Lasota, 2001). This case study describes a rare case of jejunal GIST, which was detected in a young female. A 23-year-old female patient was seen in consultation in our surgical unit with symptoms of abdominal pain, anorexia, and bowel distention. She was hospitalized for clinical investigation. Her medical history revealed that she had melena twice in the last 6-month period. Physical examination revealed an immobile mass in her left abdomen. The laboratory examination revealed anemia with a hemoglobin of 8.5 g/dL and a normal carcinoembryonic antigen level. The upper GI endoscopy was normal. Her terminal ileum and colon were normal endoscopically. On abdominal computed tomography examination, a solid 10 × 9 × 7 cm jejunal mass was detected (Figure 1). After preoperative preparations, the patient underwent explorative laparotomy and a jejunal mass was detected at 60 cm beyond the ligament of Treitz. The tumor invaded the outer serosal layer (Figure 2). The mass was resected with adequate clear surgical margins and an end-to-end anastomosis was performed. She was discharged on postoperative day 7 without complication. Pathologic examination of the
OF GASTROENTEROLOGY NURSES AND ASSOCIATES, INC. AND THE CANADIAN SOCIETY OF GASTROENTEROLOGY NURSES AND ASSOCIATES DEDICATED TO THE SAFE AND EFFECTIVE PRACTICE OF GASTROENTEROLOGY AND ENDOSCOPY NURSING
About the authors: Hakan Bulus, MD, is Specialist, Department of Surgery, Keçiören Training and Research Hospital, Ankara, Turkey. Adnan Tas, MD, is Specialist, Department of Gastroenterology, Mustafa Kemal University Faculty of Medicine, Hatay, Turkey. Ahmet Koyuncu, MD, is Specialist, Department of Surgery, Keçiören Training and Research Hospital, Ankara, Turkey. The authors declare no conflict of interest. DOI: 10.1097/SGA.0000000000000052
246 Copyright © 2014 Society of Gastroenterology Nurses and Associates
Gastroenterology Nursing Copyright © 2014 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited
GNJ-D-13-00006.indd 246
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Clinical Case Study
FIGURE 1. Abdominal computed tomographic image showing the jejunal mass.
specimen showed GIST derived from the jejunum. Mitotic activity was normal. Necrosis was not found. Her CD 117, SMA, and S-100 protein laboratory results were positive (Figure 3). Gastrointestinal stromal tumor is primarily male dominant and mostly seen in individuals over the age of 40 years. This type of tumor is usually asymptomatic and detected incidentally during another surgical intervention or radiological study (Miettinen & Lasota, 2001; Nishida et al., 1998). This case was unusual in that it was a young female patient admitted to hospital with abdominal pain, anorexia, and bowel distention. Diagnosis of GIST was confirmed with pathological examination and immunohistochemical investigation. Recent studies have shown that GIST markers include increased expressions of CD 117 and CD 34 (Fujimoto, Nakanishi, Yoshimura, & Shimoda, 2003; Hasegawa, Matsuno, Shimoda, & Hirohashi (2003). In our case,
immunohistochemical positivity of CD 117, SMA, and S100 proteins was also detected. A GIST is classified in terms of recurrence and metastatic potential as low-, medium-, and high-risk groups (Miettinen & Lasota, 2001). A tumor greater than 5 cm in size has the most probability of a malignancy characteristic. However, tumor size alone does not reflect full prognostic value. Besides tumor size, necrosis, aneuploidy, high mitotix index, and peritoneal dissemination on surgical exploration are also important factors of poor prognosis (Nishida et al., 1998). In this case, the resected GIST specimen had low mitotic index andv no necrosis, but the tumor was 10 cm in size. In conclusion, although jejunal GIST is rarely seen, we have presented an atypical presentation of this disease. We saw that jejunal GIST may bring about both massive GI bleeding and occult bleeding in the stool.
FIGURE 2. Intraoperative jejunal mass.
FIGURE 3. Immunohistochemical investigation stated that the mass is jejunal gastrointestinal stromal tumor.
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247
Copyright © 2014 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited
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Clinical Case Study REFERENCES Fujimoto, Y., Nakanishi, Y., Yoshimura, K., & Shimoda, T. (2003). Clinicopathologic study of primary malignant gastrointestinal stromal tumor of the stomach, with special reference to prognostic factors: Analysis of results in 140 surgically resected patients. Gastric Cancer, 6, 39–48. Hasegawa, T., Matsuno, Y., Shimoda, T., & Hirohash, I. S. (2003). Gastrointestinal stromal tumour: Consistent CD117 immunostaining for diagnosis, and prognostic classification based on tumor size and MIB-1 grade. Human Pathology, 33(6), 669–676.
Mazur, M. T., & Clark, H. B. (1983). Gastric stromal tumors. Reappraisal of histogenesis. American Journal of Surgical Pathology, 7, 507–519. Miettinen, M., & Lasota, J. (2001). Gastrointestinal stromal tumors definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis. Virchows Archiv, 438, 1–12. Nishida, T., Hirota, S., Taniguchi, M., Hashimoto, K., Isozaki, K., Nakamura, H., … Kitamura, Y. (1998). Familial gastrointestinal stromal tumours with germline mutation of the KIT gene. Nature Genetics, 19(4), 323–324.
248 Copyright © 2014 Society of Gastroenterology Nurses and Associates
Gastroenterology Nursing Copyright © 2014 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited
GNJ-D-13-00006.indd 248
5/21/14 6:54 PM
LeAnne Vitito, MS, RN, CGRN, APRN Department Editor
A RARE CAUSE OF GASTROINTESTINAL BLEEDING IN A YOUNG FEMALE: JEJUNAL GASTROINTESTINAL STROMAL TUMOR Hakan Bulus, MD Adnan Tas, MD Ahmet Koyuncu, MD
G
THE OFFICIAL JOURNAL OF THE SOCIETY
astrointestinal stromal tumor (GIST) was first described by Mazur and Clark (1983) in 1983, as a rare oncologic entity derived from cajal progenitor cells (Nishida et al., 1998). The GIST is among the rare tumors composing 1% of all gastrointestinal (GI) tumors and is most often seen in the stomach (60%–70%) (Miettinen & Lasota, 2001). This case study describes a rare case of jejunal GIST, which was detected in a young female. A 23-year-old female patient was seen in consultation in our surgical unit with symptoms of abdominal pain, anorexia, and bowel distention. She was hospitalized for clinical investigation. Her medical history revealed that she had melena twice in the last 6-month period. Physical examination revealed an immobile mass in her left abdomen. The laboratory examination revealed anemia with a hemoglobin of 8.5 g/dL and a normal carcinoembryonic antigen level. The upper GI endoscopy was normal. Her terminal ileum and colon were normal endoscopically. On abdominal computed tomography examination, a solid 10 × 9 × 7 cm jejunal mass was detected (Figure 1). After preoperative preparations, the patient underwent explorative laparotomy and a jejunal mass was detected at 60 cm beyond the ligament of Treitz. The tumor invaded the outer serosal layer (Figure 2). The mass was resected with adequate clear surgical margins and an end-to-end anastomosis was performed. She was discharged on postoperative day 7 without complication. Pathologic examination of the
OF GASTROENTEROLOGY NURSES AND ASSOCIATES, INC. AND THE CANADIAN SOCIETY OF GASTROENTEROLOGY NURSES AND ASSOCIATES DEDICATED TO THE SAFE AND EFFECTIVE PRACTICE OF GASTROENTEROLOGY AND ENDOSCOPY NURSING
About the authors: Hakan Bulus, MD, is Specialist, Department of Surgery, Keçiören Training and Research Hospital, Ankara, Turkey. Adnan Tas, MD, is Specialist, Department of Gastroenterology, Mustafa Kemal University Faculty of Medicine, Hatay, Turkey. Ahmet Koyuncu, MD, is Specialist, Department of Surgery, Keçiören Training and Research Hospital, Ankara, Turkey. The authors declare no conflict of interest. DOI: 10.1097/SGA.0000000000000052
246 Copyright © 2014 Society of Gastroenterology Nurses and Associates
Gastroenterology Nursing Copyright © 2014 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited
GNJ-D-13-00006.indd 246
5/21/14 6:54 PM
Clinical Case Study
FIGURE 1. Abdominal computed tomographic image showing the jejunal mass.
specimen showed GIST derived from the jejunum. Mitotic activity was normal. Necrosis was not found. Her CD 117, SMA, and S-100 protein laboratory results were positive (Figure 3). Gastrointestinal stromal tumor is primarily male dominant and mostly seen in individuals over the age of 40 years. This type of tumor is usually asymptomatic and detected incidentally during another surgical intervention or radiological study (Miettinen & Lasota, 2001; Nishida et al., 1998). This case was unusual in that it was a young female patient admitted to hospital with abdominal pain, anorexia, and bowel distention. Diagnosis of GIST was confirmed with pathological examination and immunohistochemical investigation. Recent studies have shown that GIST markers include increased expressions of CD 117 and CD 34 (Fujimoto, Nakanishi, Yoshimura, & Shimoda, 2003; Hasegawa, Matsuno, Shimoda, & Hirohashi (2003). In our case,
immunohistochemical positivity of CD 117, SMA, and S100 proteins was also detected. A GIST is classified in terms of recurrence and metastatic potential as low-, medium-, and high-risk groups (Miettinen & Lasota, 2001). A tumor greater than 5 cm in size has the most probability of a malignancy characteristic. However, tumor size alone does not reflect full prognostic value. Besides tumor size, necrosis, aneuploidy, high mitotix index, and peritoneal dissemination on surgical exploration are also important factors of poor prognosis (Nishida et al., 1998). In this case, the resected GIST specimen had low mitotic index andv no necrosis, but the tumor was 10 cm in size. In conclusion, although jejunal GIST is rarely seen, we have presented an atypical presentation of this disease. We saw that jejunal GIST may bring about both massive GI bleeding and occult bleeding in the stool.
FIGURE 2. Intraoperative jejunal mass.
FIGURE 3. Immunohistochemical investigation stated that the mass is jejunal gastrointestinal stromal tumor.
VOLUME 37
|
NUMBER 3
|
MAY/JUNE 2014
247
Copyright © 2014 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited
GNJ-D-13-00006.indd 247
5/21/14 6:54 PM
Clinical Case Study REFERENCES Fujimoto, Y., Nakanishi, Y., Yoshimura, K., & Shimoda, T. (2003). Clinicopathologic study of primary malignant gastrointestinal stromal tumor of the stomach, with special reference to prognostic factors: Analysis of results in 140 surgically resected patients. Gastric Cancer, 6, 39–48. Hasegawa, T., Matsuno, Y., Shimoda, T., & Hirohash, I. S. (2003). Gastrointestinal stromal tumour: Consistent CD117 immunostaining for diagnosis, and prognostic classification based on tumor size and MIB-1 grade. Human Pathology, 33(6), 669–676.
Mazur, M. T., & Clark, H. B. (1983). Gastric stromal tumors. Reappraisal of histogenesis. American Journal of Surgical Pathology, 7, 507–519. Miettinen, M., & Lasota, J. (2001). Gastrointestinal stromal tumors definition, clinical, histological, immunohistochemical, and molecular genetic features and differential diagnosis. Virchows Archiv, 438, 1–12. Nishida, T., Hirota, S., Taniguchi, M., Hashimoto, K., Isozaki, K., Nakamura, H., … Kitamura, Y. (1998). Familial gastrointestinal stromal tumours with germline mutation of the KIT gene. Nature Genetics, 19(4), 323–324.
248 Copyright © 2014 Society of Gastroenterology Nurses and Associates
Gastroenterology Nursing Copyright © 2014 Society of Gastroenterology Nurses and Associates. Unauthorized reproduction of this article is prohibited
GNJ-D-13-00006.indd 248
5/21/14 6:54 PM
