Spontaneous rupture of a gastrointestinal stromal tumour

Clinical History

A 64-year-old man was admitted to the emergency department of our hospital, complaining of strong abdominal pain. His medical history revealed cholecystectomy and postoperative herniation surgery. Blood tests included: WBC 17050/μl, CRP 6.6 mg/dl and HCT 34.8%. An emergency abdominal CT was requested.

Imaging Findings

The CT examination (non-enhanced and contrast-enhanced images) showed a large left abdominal mass, 130.7 x 126 x 115.2 mm in size, with necrosis, haemorrhagic components and air bubbles inside. The mass was in contact with small bowel loops, not clearly defined, due to its rupture into the peritoneal cavity. As a result, massive haemoperitoneum was depicted. Because of the patient’s haemodynamic instability, an emergency laparotomy was performed. It revealed a ruptured tumour, arising from the jejunum, with necrotic and haemorrhagic components and massive haemoperitoneum.
The patient underwent segmental enterectomy with tumour resection and end-to-end anastomosis, as well as peritoneal lavage. The histopathological examination revealed stromal tumour of the small intestine, intermediate risk of malignancy.
The postoperative course was uneventful and the patient was discharged on the eighth postoperative day.

Discussion

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours arising from the gastrointestinal tract. GISTs are characterized by the expression of c-KIT protein (CD 117, stem cell factor receptor). This protein, which is detected via immunohistochemical analysis, is a key diagnostic criterion for GIST [1].
These tumours occur more frequently in the stomach (60% of all cases), followed by the small bowel (30%). Other sites include the colon and rectum (5%) and the oesophagus (<5%) [2]. They typically originate from the muscularis propria of the gastrointestinal tract wall and have a propensity for exophytic growth.
GIST is usually asymptomatic as long as it is relatively small. As the tumour grows, a variety of symptoms, such as abdominal discomfort, pain, dysphagia, bloating, can develop. Signs of a palpable abdominal mass or anaemia from gastrointestinal bleeding are common clinical manifestations of GIST. Most GISTs are larger than 5 cm in diameter at the time of diagnosis.
Spontaneous rupture into the peritoneal cavity with haemoperitoneum, is an extremely rare, life-threatening clinical presentation of this tumour and requires an immediate surgical approach [3, 4]. The reason for this spontaneous rupture is not entirely clear. Cheon suggested progressive weakening of the cystic wall and a trigger activity towards rupture from the movement of the intestine [5].
Computed Tomography of ruptured GIST (non-enhanced and contrast-enhanced images) usually demonstrates a large, exophytic, hypervascular tumour with heterogenous enhancement due to haemorrhage, necrosis or cystic degeneration and concomitant haemoperitoneum [6].
Segmental gastrectomy or enterectomy, tumour resection, as well as abundant peritoneal lavage should be performed in case of ruptured GIST.

Differential Diagnosis List

Final Diagnosis

Ruptured gastrointestinal stromal tumour

URL:	https://www.eurorad.org/case/10629
DOI:	10.1594/EURORAD/CASE.10629
ISSN:	1563-4086