Ileoileal intussusception induced by a gastrointestinal stromal tumor

Jejunojejunal intussusception with chronic bleeding caused by gastrointestinal stromal tumor: a case report and literature review

Background

Intussusception is a rare clinical condition in adults. The majority of patients present with symptoms of bowel obstruction. Intussusception is often misdiagnosed and the majority of cases are diagnosed intraoperatively. In this paper, we present a rare case of adult jejunojejunal intussusception with chronic bleeding caused by a gastrointestinal stromal tumor (GIST). We emphasize the role of contrast-enhanced computed tomography (CT) and enteroscopy in the presurgical diagnosis and the good prognosis in the high-risk GIST patient after surgery and targeted therapy.

Case Description

Herein, we present the case of a 63-year-old female patient with small bowel intussusception with chronic bleeding caused by a GIST. Her main symptoms were intermittent melena and progressive anemia. She had a 20-year history of hypertension and had never undergone previous abdominal surgery. After failure of an esophagogastroduodenoscopy and colonoscopy to locate the hemorrhagic foci in the gastrointestinal tract, contrast-enhanced CT and enteroscopy were used and a small bowel intussusception and an intraluminal mass with a bleeding ulcer was identified. The patient underwent laparoscopic partial small bowel resection, and postoperative pathological examinations showed a small intestinal GIST with a high risk of recurrence. It was suggested that the patient take imatinib regularly for at least 3 years. At the time of writing, she has remained in good health without relapse for 24 months after discharge. We also review 20 published cases of intussusception caused by small bowel GIST in the PubMed database.

Conclusions

Obscure gastrointestinal hemorrhage needs meticulous examinations to promptly determine the cause and location of bleeding. This case and literature review revealed that comprehensive surgical resection-centered treatment was the standard treatment for primary localized GISTs in patients at significant risk of relapse.

Life-threatening bleeding with intussusception due to gastrointestinal stromal tumor: a case report

Background

Massive intraluminal bleeding requires urgent intervention and management. However, the source of bleeding on the small intestine is difficult to determine. Intestinal tumor with intussusception is a rare and normally not an urgent condition. Herein, we present a rare case of intestinal intussusception with massive bleeding due to jejunal gastrointestinal stromal tumor (GIST) that required emergency surgical treatment.

Case presentation

A 51-year-old male was admitted to the emergency department complaining of abdominal pain and acute hematochezia. Esophagogastroduodenoscopy (EGD) and colonoscopy could not determine the source of the bleeding site. Abdominal pelvic computed tomography (AP-CT) revealed GIST with intussusception, strongly suggestive of distal jejunal bleeding. Unresponsive transfusion with low blood pressure and continuous hematochezia led to emergency laparotomy. GIST, which was the leading point for intussusception, was located in the jejunum and showed mucosal ulceration of approximately 3.5 cm in diameter. Following resection and functional anastomosis, histology revealed a GIST with low mitotic count (< 5 per 50HPF). Moreover, immunochemical analysis revealed positivity for c-kit (CD117) and DOG-1. There were no complications 2 months after surgery.

Conclusions

Intussusception associated with GIST is a rare finding that can be life-threatening if it occurs with an ulcer. This case showed that the early detection of bleeding and emergency surgery could prevent severe complications.

Adult Intussusception due to Gastrointestinal Stromal Tumor: A Rare Case Report, Comprehensive Literature Review, and Diagnostic Challenges in Low-Resource Countries

We present a rare case of gastrogastric intussusception due to gastrointestinal stromal tumor (GIST) and the largest comprehensive literature review of published case reports on gastrointestinal (GI) intussusception due to GIST in the past three decades. We found that the common presenting symptoms were features of gastrointestinal obstruction and melena. We highlight the diagnostic challenges faced in low-resource countries. Our findings emphasize the importance of early clinical diagnosis in low-resource settings in order to guide timely management. In addition, histological analysis of the tumor for macroscopic and microscopic characteristics including mitotic index and c-Kit/CD117 status should be obtained to guide adjuvant therapy with imatinib mesylate. Periodic follow-up to access tumor recurrence is fundamental and should be the standard of care.

Spontaneous peeled ileal giant lipoma caused by lower gastrointestinal bleeding: A case report

RATIONALE

Gastrointestinal subepithelial tumors (SETs) with endoscopic features such as ulceration, a red color change, a peeled mucosal layer, and spontaneous bleeding could have malignant potential. However, we encountered a case of a lipoma that presented features different from the generally known features of gastrointestinal SETs. Therefore, we report an interesting rare case of a terminal ileal giant lipoma with a unique feature of spontaneous peeled ulceration on the surface on endoscopy that caused gastrointestinal bleeding.

PATIENT

An 82-year-old woman with a 1-week history of abdominal pain and hematochezia presented to our hospital.

DIAGNOSES

Ileocolonoscopy revealed a SET with a peeled surface and erythematous and ulcerative mucosal changes as well as exposed a submucosal mass at the terminal ileum. Macroscopically, the lesion appeared as a yellowish pedunculated polypoid mass measuring 3 × 2 cm with a peeled mucosal ulceration. Histopathological findings revealed a submucosal lipoma of the terminal ileum.

INTERVENTION

We thought that the endoscopic finding indicated malignant SETs or those with malignant potential rather than benign SETs. Therefore, the patient underwent an elective laparoscopic ileocecectomy.

LESSONS

We encountered a lipoma that did not present with the typical features of gastrointestinal SETs. Our findings suggest that clinicians should consider that benign SETs in the terminal ileum may present with various endoscopic findings similar to those of malignant SETs, which can cause fatal symptoms and signs.

An infrequent case of intussusception caused by gastrointestinal stromal tumor in an adult patient

Intussusception may occur anywhere in the gastrointestinal system. Unlike its idiopathic childhood counterpart, it is uncommon during adult life and a definitive cause is usually found; almost half of cases develop with malignancy. Gastrointestinal stromal tumors (GIST) originate from interstitial Cajal cells of the gastrointestinal tract. They more frequently occur in the stomach and small intestines, and often grow extraluminally, making it unlikely to cause an obstruction or bleeding. Presently described is an unusual instance of ileo-ileal intussusception due to GIST.

A rare case of jejuno-ileal intussusception secondary to a gastrointestinal stromal tumour

Gastrointestinal stromal tumours (GISTs) are rare tumours, making up 0.2-1% of gastrointestinal malignancies [Zakaria and Daradkeh (Jejunojejunal intussusception induced by a gastrointestinal stromal tumour. Case Rep Surg 2012; 2022: :173680)]. Their relative rarity combined with non-specific presentation results in tumours often remaining undiagnosed until surgery or histological examination [Martis et al. (A rare case of jejunojejunal intussusception in an adult. Indian J Surg 2013; 75: (Suppl 1):18-20)]. Presentation as a lead point for intussusception is particularly rare. We present the first case of GIST leading to intussusception at the jejuno-ileal junction in an otherwise well patient prior to presentation. Provisional diagnosis was made during emergency laparotomy, and confirmed through histological analysis. A typical immunohistochemical profile was identified, after which the patient was commenced on adjuvant imatinib therapy. We discuss classical presentation of intussusception and GIST. Further considerations of the investigation and treatment options of GISTs are also presented.

Surgical Alternatives in the Treatment of Intestinal Intussusceptions Resulting from Polyps in Adults

Adult intussusception is an uncommon disease requiring surgical intervention. The aim of this study is to discuss the surgical alternatives and share our experience in the treatment of adult patients with intussusceptions formed as a result of polyps. The retrospective study included 16 adult patients who underwent surgery after the diagnosis of intestinal invaginations resulting from polyps between the years 2000 and 2011. Sixteen patients (seven males and nine females; mean age, 48.18 years; range, 18 to 76 years) presented with intestinal intussusceptions. Although a preoperative diagnosis was carried out in 11 (68.75%) patients, the diagnosis was made intra-operatively in five patients (31.25%). Among the patients, seven (43.8%) had undergone emergency surgeries and nine (52.8) had elective surgery. The invagination in 12 patients (75%) was located in the small intestine, in two patients (12.5%) in the colon, and in a further two patients (12.5%), it was ileocecally located. Ten patients (62.5%) had segmental resection 1 anastomosis; three patients underwent (18.8%) segmental resection 1 enterostomy, and three (18.8%) received hemicolectomies. In adults, surgical treatment is always the primary option in intussusceptions resulting from polyps. Although the surgical method of choice in colonically located ones is en bloc resection without reduction, because the polyps located in the small intestine are usually of a benign nature, segmental resection with reduction should be performed in elective surgery and segmental resection without reduction should be performed in emergency cases.

Small Bowel Obstruction in a Neurofibromatosis Patient-A Rare Presentation of Gastro-Intestinal Stromal Tumors (GISTs): Case Report and Literature Review

Gastrointestinal stromal tumours (GISTs) are infrequently encountered, mesenchymal tumours of the gastrointestinal tract of varying malignant potential. Multiple (in hundreds) small intestinal GISTs have been reported to occur only very occasionally in patients with type 1 neurofibromatosis (NF1). They are mostly silent, often detected incidentally or when complicated by bleeding or other symptoms. Such a case of multiple jejunal GISTs causing small bowel obstruction in a patient with NF1 is described and relevant literatures are briefly discussed.

Ileoileal intussusception secondary to an ileal fibroma

Intussusception is defined as the telescoping of a segment of the gastrointestinal tract (intussusceptum) into an immediately adjacent distal bowel (intussuscipiens). Intussusception is a relatively rare cause of intestinal obstruction in adults. Unlike in children, a lead point is present in 90% of adult cases. The most common causes of small bowel intussusception are benign, usually hamartomas, lipomas, inflammatory polyps, adenomas and leiomyomas, in contrast to the large intestine where malignant tumors, usually adenocarcinomas, are more common. The clinical presentation of adult intussusception is non-specific with variable manifestations, predominantly those of intestinal obstruction, often making the diagnosis a challenge. The onset of symptoms may be acute, intermittent or chronic. We present a rare case of an ileal fibroma presenting with intussusception. A 43-year-old woman presented to our outpatient clinic with a history of recurrent abdominal pain. The clinical presentation and CT scan findings led to the diagnosis of ileoileal intussusception. Subsequently she underwent laparotomy which revealed an ileal fibroma as the lead point of the intussusception. Surgical exploration remains essential for diagnosis and treatment since in the majority of cases a pathologic lead point is identified. Ileal fibroma is an uncommon benign neoplasm of the small bowel and must be considered in the differential diagnosis for small bowel intussusception.

Colonoscopy Leads to A Diagnosis of A Jejunal Gastrointestinal Stromal Tumour (GIST)

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the gastrointestinal (GI) tract, but are the least common of small intestinal malignant neoplasms. While GI bleeding is the most common clinical presentation of GISTs, intussusception and obstruction are uncommon, as GISTs rarely grow into the lumen. We describe an unusual case of a 50-year-old male who presented with intermittent obscure, overt GI bleeding requiring multiple hospital admissions and blood transfusions. His work-up included abdominal CT imaging, small bowel follow-through, gastroscopies, push enteroscopy, colonoscopies, and anterograde and retrograde double-balloon enteroscopies. Complicating his presentation were colonic angiodysplasias and the development of recurrent venous thromboembolism requiring anticoagulation. Within an hour after an apparently uncomplicated colonoscopy, he developed an acute abdomen secondary to a jejunal intussusception, which led to a laparoscopic small bowel resection and the diagnosis of a jejunal GIST. Given his GIST had no high-risk features, ongoing surveillance with abdominal CT imaging was arranged. This case illustrates the complex presentation and diagnostic difficulty of a jejunal GIST causing obscure, overt GI bleeding and this is the first reported case of a jejunal intussusception following colonoscopy. Due to its submucosal location, multiple endoscopic approaches had failed to diagnose the GIST prior to surgery.

A rare cause of jejunojejunal intussusception in an adult

Jejunojejunal intussusceptions are not common in adults and unlike in children, a lead point is usually found. The clinical presentation in adults tends to be more chronic or intermittent and include abdominal pain, obstructive symptoms, gastrointestinal bleeding or palpable mass. These unspecific symptoms often lead to a late diagnosis. The clinical picture is subtle and diagnosis is therefore elusive. We report a case of jejunojejunal intussusception secondary to gastrointestinal stromal tumor (GIST) in a 50 year old female.

Unusual features of gastrointestinal stromal tumor on PET/CT and CT imaging

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract. It can be benign or malignant in behavior. Stomach, being the most common site (70%) for GISTs, is followed by the small intestine (20%). Anorectal, colonic, and esophageal GISTs are uncommon, whereas extraintestinal GISTs are extremely rare. The presenting symptoms are highly dependent on tumor size and location, although a large number of GISTs are asymptomatic. The purpose of this article is to highlight the unusual characteristics of GISTs illustrated by PET/CT and CT imaging. These characteristics are organized into (1) unusual tumor location, (2) unusual clinical presentation, and (3) unusual sites of metastasis. Knowing the uncommon features of GISTs is important, as they are more often seen nowadays with the increasingly important role of PET/CT and CT in GIST management; and these tumors are associated with a poorer prognosis and unwanted delay in diagnosis is avoidable. With the availability of effective treatment by imatinib mesylate, a prompt and early diagnosis is essential for disease control. All GISTs illustrated in this article are pathologically proven.

Adult intussusception in Northern India

BACKGROUND

Adult intussusception is infrequently encountered in Asians. The diagnosis is often late because of the variable presentation. The optimal treatment is not universally agreed upon.

PURPOSE

To determine the causes and management of this uncommon entity in India.

METHODS

A retrospective review of patients with postoperative diagnosis of intussusception between March 2003 and March 2008 was conducted in a tertiary care centre in North India. Data relating to diagnosis, treatment and histopathology was analyzed.

RESULTS

Twenty-seven patients, aged 15-72 years with 28 intussusceptions were studied. Four patients (14.29%) had acute presentation, 16 (57.14%) subacute and 7 (25%) had chronic symptoms. The most common type of intussusception was enteroenteric. A diagnosis of intussusception on contrast enhanced computed tomogram was made in 84% and a lead point was identified in 89%. A causative factor could be identified in 89% (25 out of 28 intussusceptions) which was malignant in 37% and benign in 48%. The most common underlying malignant lesions were adenocarcinoma (50%), and lymphoma (25%). Among benign lesions, small bowel polyps were the most common (57%). All cases underwent surgical intervention. Bowel resection was performed in 89%. There was no mortality.

CONCLUSION

Our series highlights a high frequency of a demonstrable cause of intussusception in a tropical country. Overall our results are similar to those reported from other countries. Resection of the involved bowel is recommended because of high incidence of underlying pathology.