Gastroenterology
Volume 137, Issue 2 , Pages e3-e4, August 2009

Atypical Cause of Abdominal Pain

  • Joanna Ying-Jiin Chen, MD

      Affiliations

    • Department of Emergency Medicine, Mackay Memorial Hospital, Hsinchu, Taiwan
    • ,
  • Chien-Kan Chen, MD

      Affiliations

    • Department of Emergency Medicine, Mackay Memorial Hospital, Hsinchu, Taiwan
    • ,
  • Kuo-Ming Chang, MD

      Affiliations

    • Department of Pathology and Laboratory Medicine, Mackay Memorial Hospital, Hsinchu, Taiwan

published online 29 June 2009.

Article Outline

 

See related article, Goh BKP et al, on page e5.

Question: A 58-year-old woman, with hypertension under medication control, presented to the emergency department because of 2 episodes of fever over the past 5 days. She mentioned a chronic, dull, aching pain over her epigastrium for the past half a year despite antacid treatment, which worsened during the recent few weeks. Laboratory study was unremarkable expect for mild leukocytosis. Esophagogastroduodenoscopy showed 3 healed gastric ulcers (2–3 mm) with erosions over the gastric antrum. Abdominal sonography detected abnormal intrahepatic gases, and the whole-abdominal computed tomography (CT) revealed the presence of portal venous gases (PVG), especially over the left lobe of the liver (Figure A), and a 7-cm, thin-walled, cystic mass containing fluid and air located between the liver, stomach, and pancreas (Figure B). CT-guided percutaneous drainage was performed, with the aspiration of brown pus. Follow-up CT abscessogram noted a localized contrast leakage into the lumen of the stomach antrum (Figure C), suggesting possible gastric microperforation and subsequent abscess formation. The culture of the abscess aspirant showed mixed organisms of Bacteroids capillosus, Prevotella buccae, and anaerobic bacteria. She remained febrile despite drainage and antibiotic treatment; operative debridement was scheduled 5 days after. The mass bulk was removed as completely as possible and an unusual adhesion between the mass and the pancreas was observed as well. What is the diagnosis?

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Answer to the Clinical Challenges and Images in GI Question: Image 2: Gastrointestinal Stromal Tumor 

Under microscopy, the operative specimen consisted of clumps of necrotic debris admixed with acute inflammatory cells and blood, as well as inflamed fibrotic tissues, compatible with the content and the wall of an abscess (Figure D-7). In some small areas, preserved viable fascicles of fairly uniform spindle tumor cells could be identified, with neither hypercellularity nor frank nuclear atypia (Figure D-2). Figure D-3 showed viable tumor tissues under the Hematoxylin and Eosin (H&E) stain. The tumor cells showed positive staining for CD117 (c-kit) (Figure D-4) and CD34, but negative for actin and S100. The diagnosis was a gastrointestinal stromal tumor (GIST), probably exophytically growing from the gastric wall, with massive necrosis and abscess formation. Afterward, the patient was referred to the department of hematology for adjuvant chemotherapy of imatinib mesylate. Despite being the most common nonepithelial neoplasm of the gastrointestinal tract, GISTs, originating from smooth muscle cells and differentiating toward the interstitial cells of Cajal, constituted only about 1% of primary gastrointestinal cancers.1 They typically involved the stomach and the small intestine, appearing as a hypodense lesion or a heterogenous mass, and they often locate immediately adjacent to the gut lumen under CT.2 There was another case with similar features: intra-abdominal abscess with connection to the gastric lumen.3 Comparatively, the case we presented here posed the most unusual presentation: PVG and a large, intra-abdominal abscess with microconnection with gastric lumen, Figure D.

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References 

  1. Pidhorecky I, Cheney RT, Kraybill WG, et al. Gastrointestinal stromal tumors: current diagnosis, biologic behavior, and management. Ann Surg Oncol. 2000;7:705–712
  2. Kim HC, Lee JM, Kim KW, et al. Gastrointestinal stromal tumors of the stomach: CT findings and prediction of malignancy. Am J Roentgenol. 2004;183:893–898
  3. Osada T, Nagahara A, Kodani T, et al. Gastrointestinal stromal tumor of the stomach with a giant abscess penetrating the gastric lumen. World J Gastroenterol. 2007;13:2385–2387

 Conflicts of interest The authors disclose no conflicts.

PII: S0016-5085(09)00148-6

doi:10.1053/j.gastro.2008.12.069

Refers to article:

  • Linking Article with CGH An Unusual Cause of a Pancreatic Head Tumor , 29 June 2009

    Brian K.P. Goh, Sittampalam M. Kesavan, Wai-Keong Wong
    Gastroenterology August 2009 (Vol. 137, Issue 2, Pages e5-e6)

Gastroenterology
Volume 137, Issue 2 , Pages e3-e4, August 2009

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