Incidental detection of a bleeding gastrointestinal stromal tumor on Tc-99m red blood cell scintigraphy
A 40-year-old man presented with a history of rectal bleeding for two days, with a reported loss of more than 1 liter of fresh blood. Despite intensive fluid management with whole blood and normal saline, his hemoglobin dropped to 4.2 mg/dl and he lapsed into delirium. Since oxygen saturation of blood was low, he was ventilated through endotracheal intubation. Colonoscopy was not attempted because of continuous bleeding. Tc-99m labeled red blood cell (RBC) scintigraphy [] showed accumulation and movement of tracer in the mid-abdomen, corresponding to the region of the jejunal loops. A diagnosis of active gastro-intestinal bleed (likely to be from the jejunum) was made, and the patient taken up for exploratory laparotomy. A polypoidal exophytic mass about 4 cm in size was found in the jejunal wall, 40 cm from the duodeno-jejunal junction. The mass along with the adjoining jejunal loops was resected, followed by end-to-end anastomosis. Gross examination of the specimen [Figure and ] showed a polypoidal mass (measuring 3.2 cm in its largest dimension) arising from the serosal aspect, producing a bulge in the central part of the mucosa, which was ulcerated and could be the possible source of bleeding. Microscopic examination [] showed a well-circumscribed tumor in the submucosa. The mass showed a spindle cell tumor arranged in long interlacing fascicles with characteristic perivascular arrangement of tumor cells. The tumor cells were moderately pleomorphic with mitotic rate of 2/50 high power field (HPF). Focally the tumor was infiltrating mucosa causing ulceration. However, the resection limits were free of tumor. Immunoperoxidase staining [] confirmed a GIST. Following surgery, the patient made a satisfactory recovery and was discharged on the seventh post-operative day.