br Case Report A year old woman

Case Report A 73-year-old woman presented with symptoms of massive hematochezia and abdominal pain. Her blood pressure was 116/58 mmHg, pulse rate 78 beats/min, and temperature 36.4°C. Abdominal examination revealed: distension, board-like rigidity, and muscular defense in the right upper quadrant; no liver dullness; inaudible bowel sounds; and a palpable mass over the right upper quadrant. Moreover, rectal examination revealed an empty ampulla. Blood tests showed a Tasquinimod level of 8.2 g/dL, white blood cell count of 14.57 × 109/L, and C-reactive protein of 0.1 mg/dL. Colonoscopic and gastroscopic evaluations were normal and did not reveal the origin of the bleeding. An abdominal enhanced computed tomography (CT) scan revealed a 9.2 cm × 10 cm solid tumor with a low density area, suggesting necrosis or abscess (Figure 1). A radiological diagnosis suspected a carcinoid or GIST arising from the jejunum. No free fluid was identified around the mass in the abdominal cavity. During hospitalization, the patient was treated with intravenous administration and blood transfusion. The patient subsequently registered improvement in her clinical condition and laboratory tests. However, sudden diffuse abdominal pain with peritonitis was noted 4 days later; we suspected that the peritonitis was induced by mass rupture and we thus performed emergency laparotomy under general anesthesia. Intraoperative findings showed an excessive bloody fluid collection, ∼1600 mL in the peritoneal cavity. An outgrown mass ruptured in the jejunum, ∼5 cm from the Treitz ligament without seeding to nearby soft tissues (Figure 2). We performed segmental resection of the jejunum with the tumor and end-to-end anastomosis. The resected mass was a well-circumscribed tumor measuring approximately 10 cm × 8 cm (Figure 3). Hematoxylin–eosin staining showed an intramuscular tumor (Figure 4), with focal hemorrhage and necrosis (Figure 5), composed of spindle-shaped and epithelioid cell proliferation (Figure 6). The mitosis index was 6 in 50 higher power fields and of a high grade (over 50 high-power fields). Immunohistochemical staining showed positive results for c-kit and DOG1 (Figure 7). The largest dimension of the tumor was 9.5 cm (pT3), and cellular atypia was moderated. We deemed the tumor to be a moderately differentiated GIST originating from the jejunum. The pathological tumor–node–metastasis stage of spontaneous rupture of the GIST of the jejunum was IIIB. The patient expired because of intestinal obstruction with community-associated pneumonia and septic shock in the postoperative period.
Discussion The annual incidence of GIST is one in 10–20 million persons, with a malignant potential of 20–30%. GISTs have a wide range of malignancy rates, and it is preferable to consider and treat them as potentially malignant. Approximately 60–70% of cases occur in the stomach, 25–35% in the small intestine, and 10% in the jejunum, whereas the esophagus, colon, rectum, and appendix are rarely affected. The clinical symptoms of a GIST range from mild to severe, and complications include vague abdominal pain, hematemesis, and intestinal obstruction. Common presentations include abdominal pain, palpable mass, gastrointestinal bleeding, fever, anorexia, weight loss, and anemia. The symptoms and signs are not disease-specific; therefore, ∼50% of GISTs have already metastasized at diagnosis, typically to the liver or peritoneum. Over the past decade, several studies have reported spontaneous perforation of jejunal GISTs. An isolated jejunal GIST associated with perforation and peritonitis is rare. GISTs originating in the jejunum seldom cause perforation and acute diffuse peritonitis. Most GISTs are > 5 cm in diameter at diagnosis; a diameter of 10 cm is associated with a higher risk of local or distant metastasis. Considering the exophytic growth of tumors, intestinal obstruction occurs because of compression rather than luminal obstruction. Pressure necrosis and an ulceration of the overlying mucosa may cause gastrointestinal bleeding, and patients with considerable blood loss may experience malaise and fatigue. Gastrointestinal bleeding is the most common presentation (50%) of GISTs and is typically associated with an ulceration of the tumor into the lumen. Perforation is generally attributed to: the replacement of the bowel wall by tumor cells; tumor embolization, leading to ischemia; and necrosis in addition to increased intraluminal pressure.