Patient is a 51-year-old female with a past medical history of hypothyroidism and pulmonary tuberculosis. Three years before seeking medical attention, she experienced mild episodes of upper abdominal pain associated with dark black, tarry feces. During the past year, these episodes became more frequent; thus, a gastroenterologist consultation was required. Anemia (Hb; 11 mg/dl) and fecal occult blood test was positive at that time. Due to this, an upper endoscopy was requested. A 103 x 46.6 mm submucosal mass in the lesser curvature 5 cm away from the cardias covered with normal mucosa was detected (Fig. 1A).
To further investigate the submucosal tumor, endoscopic ultrasound (EUS) was done, revealing that the low-echo lesion had a regular and clear margin and was inside the submucosal layer. A color doppler image showed a vascular signal extending into the center of the low-echo lesion from the periphery. EUS fine-needle aspiration was achieved for pathological evaluation and was completed safely without any complications (Fig. 1B). Immunostaining was performed, revealing positivity for CD34 and CD 117, and was negative for S100 and anti-alpha-Sm-1. Gastric GIST was diagnosed. A contrast-enhanced abdominal computed tomography (CT) unveiled the 102 x 56.3 x 46.6 mm gastric mass. It also didn't reveal any masses or lymph nodes; thus, surgery was decided, and a preoperative check-up was scheduled.
Nonetheless, as the Covid-19 pandemic started to unfold in Ecuador, most surgeries were delayed or canceled. The outpatient clinic was closed, and the quarantine combined with the fear of Covid-19 caused anxiety in the general population and affected all our patients. In our case, the patient missed her appointments and remained untreated for five months.
Since then, the patient endured the same symptoms; nonetheless, they became more severe as time passed. Suddenly, the patient underwent severe hematochezia, followed by fatigue and syncope; thus, she was brought immediately to the emergency room. On clinical evaluation, a hypotensive and diaphoretic patient was encountered. After reanimation, mild abdominal pain was detected in her upper abdomen. Complementary exams revealed severe anemia (Hb: 5.5 mg/dl), and a contrast-enhanced computed tomography revealed the previous 102 x 56.3 x 46.6 mm gastric tumor; however, contrast extravasation was seen from the tumor vessels into the gastric cavity (Fig. 2A & B). Two red cell concentrates were transfused, and surgery was decided. A laparoscopic and endoscopic cooperative approach was chosen. On laparoscopy, no masses, lymph nodes, or free liquid was seen. After this, three (10 mm, 10 mm, and 5 mm) gastrostomies were done using an ultrasound device (Harmonic, Ethicon, Johnson & Johnson), the trocars were placed through them, and the inner gastric surface was seen.
The bleeding gastric GIST was detected; it measured about 60 x 46 mm and had a 2 x 3 mm bleeding ulcer; the tumor was identified and grasped with the endoscope. After gaining adequate traction and using two consecutive 2.5 mm endo staplers (30 mm), the tumor was completely resected. After this, the tumor was extracted, the trocars were removed from the stomach, and the gastrostomies were closed using a 3-0 sterile synthetic absorbable monofilament. (PDS, Johnson & Johnson Medical) The rest of the procedure was completed without complications (Fig. 3A-C).
Pathology reported a total tumor excision; the tumors were composed of spindle cells with eosinophilic cytoplasm and low mitosis. Gastric GIST was the final diagnosis.
The postoperative course was uneventful; after blood transfusion and surgery, she remained stable, and liquids were initiated on the first postoperative day. She was discharged on postoperative day five without any complications. On follow-ups, two months later, the patient is doing well without any difficulties.