Acute upper gastrointestinal bleeding as initial manifestation of a gastrointestinal stromal tumor

An 80-years-old man was admitted to our clinic because of upper gastrointestinal bleeding with tarry stool for 3 days after taking non steroidal antiinflammatory drugs (NSAID) for back pain. The history was otherwise unremarkable. Laboratory results showed anaemia. Initial endoscopy revealed acute bleeding from an elevated ulcer in the pars inferior of the duodenum. The bleeding was successfully treated by epinephrine and fibrin injection. Biopsies showed inflammatory changes without presence of malignant cells. In the CT scan of the abdomen there was a mass near the ligament of Treitz of 6.3 cm in diameter adjacent to the duodenum. The abdominal tumor was not suitable for ultrasound-guided biopsy. Therefore, laparotomy and surgical resection of the tumor were performed. Histology showed a gastrointestinal stromal tumor (GIST) with infiltration of the muscle layer of the duodenal wall with one small local metastasis. No lymph node metastases were present. The tumor was surgically completely removed and the regular follow-up examinations have fo far shown no evidence for tumor recurrence or metastases. In upper gastrointestinal bleeding from unusual sites, GIST has to be considered as an underlying disease even if endoscopic biopsies are negative for neoplastic changes.