Splenic artery aneurysm presenting with clinical features of a bleeding gastric gastrointestinal stromal tumour
JSCR
Journal of Surgical Case Reports
http://jscr.co.uk
Splenic artery aneurysm presenting with clinical features of a bleeding gastric gastrointestinal stromal tumour
0 Authors: J Barnes (1) , G Bouras (1), L Cooper (1), FT Lam (1), J Shearman (2), V Menon (1) Location: (1 ) Department of General Surgery, University Hospital , Coventry , UK ( 2) Gastrointestinal Unit, Warwick Hospital , Warwick, UK Citation: Barnes J, Bouras G, Cooper L, Lam FT, Shearman J , Menon V. Splenic artery aneurysm presenting with clinical features of a bleeding gastric gastrointestinal stromal tumour. JSCR. 2011 6:1
Gastrointestinal stromal tumours often present with insidious upper gastrointestinal symptoms. Initial definitive diagnosis can be difficult and therefore misdiagnosis is not infrequent. Here we report a case of upper GI bleeding caused by a splenic artery aneurysm that was misdiagnosed as a gastric GIST. This rare presentation of splenic artery aneurysm highlights the potential pitfalls of investigation in upper gastrointestinal disease. Gastrointestinal stromal tumours (GIST) are neoplastic lesions of the gastrointestinal tract that commonly arise in the stomach and are being diagnosed with increasing frequency. The diagnosis is often made at gastroscopy although some lesions are detected through imaging. The grade of GIST can vary and is assessed using the mitotic index from histology (1). High grade GIST are uncommon and tend to be large at presentation with invasion into other organs and/or metastases. Patients with GIST frequently present with insidious upper gastrointestinal symptoms. Endoscopy reveals a mural lesion with normal mucosal biopsies. Radiology is often more precise in assessing tumour size and position. Once diagnosed, elective surgical resection is recommended and allows for the assessment of tumour grade and malignant risk. Less commonly, GIST can present acutely with gastrointestinal bleeding. Several atypical presentations of malignant GIST such as hypoglycaemia and testicular mass have also been described (2,3). In addition, several others have reported misdiagnosis of non-neoplastic abdominal lesions as GIST (4,5,6). With increasing molecular characterization of such lesions, the presentation, management and treatment of GIST is of interest to surgical oncologists worldwide. Here we describe our experience with one patient who had endoscopic features typical of a bleeding gastric GIST that was subsequently found to have an atypical splenic artery aneurysm at laparotomy.
INTRODUCTION
A 32 year old professional footballer was assessed having suffered presyncope and
haematemesis whilst driving. Initial tests revealed a haemoglobin of 9g/dl, a white cell count of
17 000/ml and a C-reactive protein of 212mg/l. Upper gastrointestinal endoscopy revealed a
protruding lesion in the gastric fundus with a haemorrhagic ulcer at its apex (Figure 1).
A subsequent CT scan showed an 18cm x 8cm mass related to the stomach that was
displacing other organs in the left upper quadrant (Figure 2). The scan also revealed the
presence of a small splenic aneurysm separate to this lesion.
The diagnosis of bleeding gastric GIST was made based on these findings and the patient was
consented for laparotomy. During surgery, a large heterogenous mass was found encasing the
gastric fundus, colon and the tail of pancreas (Figure 3).
The decision was made to perform an en-bloc resection with distal pancreatectomy,
splenectomy, segmental colectomy with primary anastomosis, and gastric wedge resection
(Figure 4). The patient made an uncomplicated recovery from surgery. Histological analysis of
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the resected specimen revealed a prominent histiocytic inflammatory reaction surrounding a
splenic artery aneurysm with no features of gastrointestinal neoplasia.
DISCUSSION
True aneurysms of the splenic artery are rare outside of pregnancy, yet are still the 3rd most
common abdominal aneurysm (after aortic and iliac). They are more common in the elderly
and the incidence ranges from 0.01% to 10.4%. In approximately 30% of cases, the
aneurysm ruptures into an adjacent viscous (
7
). Aneurysms of the coeliac, hepatic and
mesenteric arteries have been previously reported to present with gastrointestinal bleeding (
8
). There are two accounts of gastrointestinal bleeding associated with splenic artery
aneurysms however these caused colonic and pancreatic bleeding (
7,8
). The present report
adds to the literature by describing for the first time a splenic artery aneurysm bleeding into the
gastric fundus and mimicking the endoscopic appearance of a bleeding gastric GIST.
This case differs from other accounts as there was a soft tissue reaction surrounding a small
splenic artery aneurysm and therefore the appearances were similar to a neoplastic mass. This
inflammatory phlegmon is presumed to be associated with a vasculitic process surrounding the
splenic artery aneurysm as reflected by the initial raised inflammatory (...truncated)