Role of hemoclips in the management of acute bleeding from a gastric stromal tumor: a case report and review of the literature
© Khashab et al; licensee BioMed Central Ltd. 2007
Received: 04 July 2007
Accepted: 14 November 2007
Published: 14 November 2007
Though gastrointestinal stromal tumors (GISTs) frequently present with gastrointestinal bleeding, the guidelines for the management and control of bleeding are unclear especially in patients who are not appropriate for surgical resection.
We report a case of gastric GIST in an elderly patient who presented with bleeding. Homeostasis was achieved initially with the endoscopic placement of a hemoclip followed by treatment with the tyrosine kinase inhibitor, imatinib.
The management of bleeding GISTs in the elderly pose a challenging task to the gastroenterologist and treatment strategies should be tailored to the expertise of the endoscopist, surgeon and other supportive staff.
Mesenchymal tumors are an infrequently encountered group of benign and malignant neoplasms of the gastrointestinal tract. Gastrointestinal stromal tumors (GISTs), account for the majority of these gastrointestinal mesenchymal tumors. Mazur and Clark  first recognized GISTs as a separate entity from gastrointestinal smooth muscle tumors in 1983 based on the different cellular origin, the intestinal pacemaker cells of Cajal for the former, and the smooth muscle cells for the latter. GISTs are often asymptomatic and discovered incidentally during endoscopic procedures. GI-related symptoms normally occur with larger tumors. Several major GIST-related symptoms are bleeding, abdominal pain, abdominal mass and obstruction. When such complications occur, surgical resection is generally recommended. In this paper, we describe the case of an 84 year-old man who presented with melena and bleeding from a gastric GIST. Surgical intervention was prohibited due to other concomitant medical illnesses. However, the bleeding was successfully controlled with hemoclip application. The management of gastrointestinal bleeding from GISTs is also reviewed.
Approximately 2000–5000 cases of GIST are diagnosed annually. The predominant site for a GIST is the stomach (52%), followed by the small intestine (25%) . The clinical presentation of a GIST largely depends on its size. Small tumors (usually measuring less than 2 cm) usually do not produce symptoms and are often detected incidentally on endoscopy or radiographic examination. Approximately one-third of patients present with GI bleeding. Bleeding can be occult and manifest as anemia, or overt and manifest as melena, hematochezia or hematemesis .
The standard therapy for GISTs regardless of presentation is complete surgical resection. In general, only a segmental resection of the organ in which the tumor originates is necessary. Meticulous surgical technique is essential as these tumors are fragile and tumor rupture increases the risk of peritoneal recurrence. Although complete resection is achieved in 85 % of patients, the 5-year survival after resection is approximately 50 % because of tumor recurrence [3, 4]. Thus other treatment modalities in addition to surgical resection are needed to improve the treatment outcome. The discovery that dysregulation in the KIT tyrosine kinase activity underlies the pathogenesis of GIST has led to the development of a novel systemic tyrosine kinase inhibitor, imatinib. This medication has revolutionized the treatment of this tumor particularly in patients who have metastatic and/or unresectable disease.
Clinical Data of four patients with stomach GIST presenting with acute GI bleeding
Recurrent upper GI bleed
Total gastrectomy, partial hepatectomy and esophagectomy
Chest discomfort and syncope
Hematemesis and melena
Coffee ground vomiting
Since surgery was prohibited in our case due to other co-morbidities, imatinib was given after endoscopic treatment. The reason for this approach was twofold. First, this medication has proven efficacy in patients with metastatic disease who are usually treated non-surgically. Second, it was given with the intent to cause regression of the size of the tumor and prevent future bleeding. In fact, upon repeating upper endoscopy three months afterwards, we found significant reduction in the size of the tumor and the ulcers were completely healed.
In a clinical scenario when surgical resection is not an option in the management of bleeding gastric GIST, the use of hemoclips, if feasible, should be considered. The therapy should be followed by imatinib with the goal to stabilize the tumor growth and lead to regression of the size of the tumor. The management of bleeding gastrointestinal stromal tumors in the elderly poses a challenge to the gastroenterologist and treatment strategies should be tailored to the expertise of the endoscopists, surgeons, and other supportive staff members.
Full verbal and written informed consent has been obtained from the patient for submission of this manuscript for publication.
The authors declare that no funding was required for the writing and submission of the manuscript.
- Mazur MT, Clark HB: Gastric stromal tumors. Reappraisal of histogenesis. Am J Surg Pathol. 1983, 7: 507-519.View ArticlePubMedGoogle Scholar
- Emory TS, Sobin LH, Lukes L, Lee DH, O'Leary TJ: Prognosis of gastrointestinal smooth-muscle (stromal) tumors: dependence on anatomic site. Am J Surg Pathol. 1999, 23: 82-87. 10.1097/00000478-199901000-00009.View ArticlePubMedGoogle Scholar
- Dematteo RP, Lewis JJ, Leung D, Mudan SS, Woodruff JM, Brennan MF: Two hundred gastrointestinal stromal tumors: recurrence patterns and prognostic factors for survival. Ann Surg. 2000, 231: 51-58. 10.1097/00000658-200001000-00008.View ArticlePubMedPubMed CentralGoogle Scholar
- Ng EH, Pollock RE, Munsell MF, Atkinson EN, Romsdahl MM: Prognostic factors influencing survival in gastrointestinal leiomyosarcomas. Implications for surgical management and staging. Ann Surg. 1992, 215: 68-77.View ArticlePubMedPubMed CentralGoogle Scholar
- Hirota S, Isozaki K, Moriyama Y, Hashimoto K, Nishida T, Ishiguro S, Kawano K, Hanada M, Kurata A, Takeda M, Muhammad TG, Matsuzawa Y, Kanakura Y, Shinomura Y, Kitamura Y: Gain-of-function mutations of c-kit in human gastrointestinal stromal tumors. Science. 1998, 279: 577-580. 10.1126/science.279.5350.577.View ArticlePubMedGoogle Scholar
- Galimberti A, Compagnoni BM, Lezziero F, Grassi M, Gariboldi M, Ferrante F: [Gastrointestinal stromal tumours and acute haemorrhage: description of four cases]. Chir Ital. 2005, 57: 337-343.PubMedGoogle Scholar
- El H, Chehal A, El Saghir NS: Recurrent GI bleeding and surgery following the initial response to imatinib therapy in GIST of the stomach. Dig Dis Sci. 2005, 50: 65-69. 10.1007/s10620-005-1279-8.View ArticleGoogle Scholar
- Yoshida H, Mamada Y, Taniai N, Mizuguchi Y, Nakamura Y, Nomura T, Okuda T, Uchida E, Fukuda Y, Watanabe M, Tajiri T: Spurt bleeding from a calcificated gastrointestinal stromal tumor in the stomach. J Nippon Med Sch. 2005, 72: 304-307. 10.1272/jnms.72.304.View ArticlePubMedGoogle Scholar
- Buragas M, Kidd M, Modlin IM, Cha C: Multiple gastrointestinal stromal tumors and synchronous ileal carcinoids. Nat Clin Pract Oncol. 2005, 2: 166-170. 10.1038/ncponc0108.View ArticlePubMedGoogle Scholar
- Lai TK, Wong WC, Chin AC, Chan RY, Huang HY, Li ET, Chu WS, Chung TK, Chan KL: Unusual bleeding gastric ulcer. Hong Kong Med J. 2006, 12: 398-399.PubMedGoogle Scholar
- Giesler T, Muller S, Schmiedehausen K, Hahn EG, Raithel M: Bleeding stromal tumor. Gastrointest Endosc. 2005, 61: 593-10.1016/S0016-5107(04)02831-7.View ArticlePubMedGoogle Scholar
- Verweij J, Casali PG, Zalcberg J, LeCesne A, Reichardt P, Blay JY, Issels R, van OA, Hogendoorn PC, van GM, Bertulli R, Judson I: Progression-free survival in gastrointestinal stromal tumours with high-dose imatinib: randomised trial. Lancet. 2004, 364: 1127-1134. 10.1016/S0140-6736(04)17098-0.View ArticlePubMedGoogle Scholar
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