Jejunal Stromal Tumor Revealed by a Digestive Hemorrhage

doi:10.4236/ijcm.2013.411085

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International Journal of Clinical Medicine, 2013, 4, 485-487

Published Online November 2013 (http://www.scirp.org/journal/ijcm)

http://dx.doi.org/10.4236/ijcm.2013.411085

Open Access IJCM

485

Jejunal Stromal Tumor Revealed by a Digestive

Hemorrhage*

Mountassir Moujahid1#, Issam Ennafae2, Mohamed Ghari2, Khalid Chekoura3, Youness Issaoui3,

My Hassan Tahiri1

1Dpartment of General Surgery, 5th Military Hospital, Guelmim, Morocco; 2Department of Radiology, 5th Military Hospital,

Guelmim, Morocc o ; 3Department of Reanimation, 5th Military Hospital, Guelmim, Morocco.

Email: #[email protected]

Received August 13th, 2013; revised September 15th, 2013; accepted October 10th, 2013

License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Introduction: Gastro intestinal stromal tumors are rare which can arise at any age, mostly between 50 and 60 years old.

They are characterized by the expression on the surface of their cells, a specific gene c-kit. They can be located in any

segment of the digestive tract, with a preference for the stomach (60%). The jejunum location is found in 200% to 30%

of the cases. The originality of our observation is the revelation of a stromal jejunum tumor by a digestive bleeding.

Case Report: A 71-year-old man was admitted in emergencies for a low digestive plentiful bleeding with state of hy-

povolemia shock. Result: The operation was performed after stabilization of his dynamic state and blood transfusion

and we discovered a jejunal stromal tumor in operation. The follow-up was simple with a good evolution under treat-

ment by Imatinib. Conclusion: Stromal digestive tumors are rare which can interest all the segments of the digestive

tract and their diagnosis must be often evoked in front of any digestive bleeding.

Keywords: Gastro Intestinal Stromal Tumor; Jejunum Location; Digestive Haemorrhage; Diagnostic and Treatment

1. Background

Digestive stromal tumors are rare that could occur at any

age, often between 50 and 60. They are characterized by

the expression on the s urface of their cells, a specific gene

c-kit. They can be located in any segment of the digestive

tube, with a preference for the stomach (60%). The Je-

junal localization is found in 20% to 30% of the cases 1.

We report a case of a stromal jejunal tumor collaged in

the service of surgery in the 5th Military Hospital at

Gu e lmim i n Mor occ o.

2. Case report

A 71-year-old patient, without a particular pathological

history, was allowed in emergencies for epigastric distress

associated with episodes of bleedi ng of big ab undance. He

was in a state of shock with 5 g/1 of haemoglobin. After

preparation and transfusion by four globular sediment, an

oesogastroduodenal endoscopy was normal and no trace

of bleeding was found.

The pelvic abdominal scanner revealed a tissular mass

developed over the flexura o f a rig ht col o n (Figure 1).

The exploration by endoscopic video capsula is not yet

practised in our training. As the bleeding persist with 6 g/l

of haemoglobin, The patient is led to the surgical unit after

transfusion and stabilization of his hemodynamic state.

The laparotomy showed a colic distension diffused with a

lot of blood, there was no tumor at the right colon but we

found a tumor situated in 25 cm of the duodeno jejunal

angle. The intervention consisted on a segmental jejunal

resectio n and en d-to-end anastomo sis ( Figures 2 and 3).

There were no postoperative complications in the early

postoperative period. We started oral feeding on the sec-

ond postoperative day with a liquid diet. The patient was

discharged home on the forth postoperative day.

Pathological examination of the specimen revealed a

GIST originating from the jejunal wall that was composed

of fusiform cells. The mitotic index was 1 in 50 higher

fields. On immune histochemical examination, CD117

and smooth muscle actin was diffusely positive, S100 was

*Conflict of interests: The authors declare no conflict of interests.

The authors’ contributions: All the authors contributed to the writing

of this ma nuscript and read and a pproved the final.

#Corresponding author.

Jejunal Stromal Tumor Revealed by a Dige sti ve Hemorrha g e

486

Figure 1. Abdominal scanner showing a tissular tumor of

heterogeneous density developed in the right of flexura co-

lon.

Figure 2. Tumor in expenses of the jejunum.

Figure 3. Segmental jejunal resection taking the tumor.

focal positive, and desmin and CD34 were negative. The

immune histochemical study confirmed the GIST.

3. Discussion

GISTs are a group of rare tumours of the digestive tract,

that could occur at any age, often between 50 and 60 with

a sex ratio close to 1 [1,2.The etiologic factors are un-

known. They are mostly localized at the level of the

stomach (60%), the small intestine (25%) and the colon in

(5 to 10%) [3,4. The incidence of these tumours is about

1–2/100 0005. They represent less than 1% of the ma-

lignant tumors of the digestive tube, and 20% of the ma-

lignant tumors in the small intestine,excluding lympho-

mas.

The extra digestive forms, the mesenteric ones in par-

ticular, are very rare: less than 5% of all the digestive

stromal tumors. The stromal tumors of the small intestine

can be asymptomatic, of fortuitous discovery in the fall of

a morphological examination or during a surgical opera-

tion as it was the case of our patient. They can be revealed

by a digestive bleeding [1,2,5,6]. The tumors of the small

intestine represent the second cause of unexplained di-

gestive bleeding 5 to 10% of the cases after the angio-

dysplasias [2,7,8].

Immunocytochemically, some tumours show differen-

tiation toward smooth muscle, others toward nerve, some

toward histiocytes, a small group toward smooth muscle

and nerve, and another small group shows no differentia-

tion [9] (http://www.hindawi.com/crim/oncological.medi

cine/2011/985242/-B8). The tumor is a major or minor

component of certain rare syndromes, familial, and non

familial functioning paraganglioma, and GIST are un-

common tumors that occur mostly in a sporadic and iso-

lated form, occasionally as components of multiple neo-

plasia syndromes, either separately or together. Separately,

they occur in several inherited syndromes including mul-

tiple endocrine neoplasia [10], the GIST, lentigines, and

mast cell tumor syndrome. Together, they are variably

prominent components of three syndromes: the familial

paraganglioma and gastric GIST syndrome, neurofibro-

matosis type 1, and the Carney triad (syndrome with

paraganglioma-jejunal GIST combination). The two for-

mer conditions are inherited as autosomal dominant traits;

the later does not appear to be inherited and affects young

women predominantly [11].

The endoscopic video capsula plays an important role

in the diagnosis of stromal hemorrhagic tumors of the

small intestine. It is a simple and harmless examination,

that represents at present the examination of first intention

in the case of an unexplain ed digestiv e h aemorrhage after

normal oesogastro duodenal endoscopy and an ileo colo-

scopy 1,2,4,9,10.The endoscopic video capsula made it

possible to put the diagnosis of tumors of the small intes-

tine in 8%, 9% of the cases [1,2,9,11,12]. Surgery is the

primary treatment of choice and for a long time has been

the only effective treatment for GIST with overall 5-year

survival rates of 45% - 55% until 200 1 when Imatinib, a

Open Access IJCM

Jejunal Stromal Tumor Revealed by a Dige sti ve Hemorrha g e

Open Access IJCM

487

small molecule inhibiting the kinase activity of c-k it, was

recognized to be highly effective in metastasized GIST

and revolutionized the treatment of metastasized and/or

unresectable GIST [13,14]. The development of coelio

surgery allows an invasive mini curative resection surgery

in most cases [7,8,15,16].

4. Conclusion

In the case of an unexplained digestive haemorrhage after

norma l ga str o du o denal e nd os co py and a n il eo col osc o py,

it is necessary to think of the hemorrhagic tumors of the

small intestine, especially the stromal tumors. Their di-

agnosis was clearly improved by the advent of the endo-

scopic vide o capsula, which i s not yet c ommon practice in

our institution.

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