Endosonographic detection of dumbbell-shaped jejunal GIST using double balloon enteroscopy

Inhaltsübersicht

The introduction of double balloon enteroscopy (DBE) into clinical practice has enabled us to examine lesions, even those located in the jejunum [1]. DBE has also been reported to be useful for the treatment of bleeding jejunal lesions [2]. We report a case of gastrointestinal stromal tumor (GIST) of the jejunum, a precise preoperative diagnosis of which was made with DBE.

A 48-year-old man was referred for evaluation of repeated bloody stools. The Hb level was 5.4 mg/dL. Esophagogastroduodenoscopy, colonoscopy, and push enteroscopy (PCF P240 AI; Olympus, Tokyo, Japan) failed to reveal any obvious lesion. DBE (EN450 T5/20; Fujinon-Toshiba ES system, Tokyo, Japan) was carried out, and a submucosal lesion was noted in the jejunum, located approximately 1 m distal to the ligament of Treitz ([Fig. 1]). A small ulceration with active bleeding was noted at the top of the lesion. Hypertonic saline epinephrine injection was successfully carried out to terminate the bleeding. Endoscopic ultrasound with a 12-MHz US catheter probe (SP-702; Fujinon-Toshiba) disclosed a dumbbell-shaped tumor in the jejunal wall ([Fig. 2]). It measured 2 cm in diameter, with a homogeneous, hypoechoic pattern. It was contiguous with the proper muscle layer ([Fig. 3]). A preoperative diagnosis of jejunal GIST was made. The lesion was resected surgically.

Fig. 1 Submucosal lesion was noted in the proximal jejunum.

Fig. 2 Endoscopic ultrasound with a 12-MHz US catheter probe disclosed a dumbbell-shaped tumor in the jejunal wall.

Fig. 3 The submucosal tumor was contiguous with the proper muscle layer.

The jejunal submucosal tumor was recognized from the outside of the lumen ([Fig. 4]). The macroscopic view of the formalin-fixed specimen revealed clearly the dumbbell shape of the tumor ([Fig. 5]); it measured 22 × 19 mm. Microscopically, the lesion was composed of interlacing bundles of spindle cells with no atypia, which derived from the proper muscle layer. No mitosis was noted (0/50 high-power field). Immunohistochemical study revealed positive staining of c-kit ([Fig. 6]) and CD34. MIB-1 labeling index was 2 %. Postoperative histologic diagnosis was jejunal GIST, classified as low risk.

Fig. 4 Intraoperative view: the jejunal submucosal tumor was recognized from the outside of the lumen.

Fig. 5 Macroscopic view of the formalin-fixed specimen of the jejunal submucosal tumor.

Fig. 6 Immunohistochemical study revealed positive staining of c-kit.

DBE is a useful modality for both diagnostic and therapeutic purposes.

Endoscopy_UCTN_Code_CCL_1AC_2AC

References

• 1 Yamamoto H, Sekine Y, Sato Y. et al . Total enteroscopy with a nonsurgical steerable double-balloon method.  Gastrointest Endosc. 2001;  53 216-220
• 2 Nishimura M, Yamamoto H, Kita H. et al . Gastrointestinal stromal tumor in the jejunum: diagnosis and control of bleeding with electrocoagulation by using double-balloon enteroscopy.  J Gastroenterol. 2004;  39 1001-1004