Gastrointestinal Stromal Tumor of Small Bowel Presenting with Hemorrhagic Shock after Blunt Trauma to the Abdomen

Abstract

GI stromal tumors (GISTs) are rare malignant tumors originating from the intestinal cells of Cajal.1 Most common site is stomach and most common presenting symptoms are nonspecific and sign is upper GI bleed, which is very uncommon. Because acute presentation is uncommon, they are not usually considered among the differential diagnosis of an acute abdomen. These tumors remain indolent for years and are found accidently; the reason for this delay in diagnosis is extraluminal or submucosal growth pattern. We describe a young patient who presented with an acute abdomen due to hemoperitoneum and shock after blunt trauma due to ruptured soft tissue mass, which was proven to be GIST after successful laparotomy. A 38-year-old man presented with acute abdomen and peritonitis after accidently sustaining kick to the abdomen while playing soccer. His systolic BP was 70/ 30, he responded transiently to fluid boluses. His CT scan of the abdomen showed a large soft tissue mass with complex density Hounsfield units varied from 13 to 75 suggestive of bleed within soft tissue mass. There was free fluid in the abdomen ( F1 Fig. 1). We proceeded with surgery, and at laparotomy, the soft tissue mass of size 7 ·7 · 3 cm with bleeding raw surface was found attached to the jejunum with a stalk. Another soft tissue mass of size 5 · 5 · 3 cm was found attached to peritoneum of right paracolic gutter. This piece seemed to be broken from primary mass over the jejunum ( F2 Fig. 2). Resection of the jejunum bearing tumor segment with primary anastomoses along with excision of soft tissue mass with partial pelvic peritonectomy was performed. The patient recovered well and was discharged on 6th postoperative day. Histology showed GIST with 4 to 5 mitosis/25 HPF. Immunohistochemistry was positive for c-KIT, CD34, and vimentin. The peritonectomy and appendectomy specimen were free of tumor. The combined size of 12 · 11 · 4 cm, location at the jejunum, mitotic rate of 5/25 High power field (HPF), and tumor rupture placed him in the high-risk category. GISTs are rare benign or malignant tumors accounting for less than 1 per cent of GI neoplasms arising from mesenchymal cells of the GI tract. These cells are c-KIT (CD117) positive. Most common site is