ELECTRONIC IMAGE OF THE MONTH
Prolapsed Gastric Gastrointestinal Stromal Tumor: A Rare Cause
of Biliary Obstruction and Acute Pancreatitis
Musa Yilmaz, Juan Ibarra, and Benjamin Leon Musher
Baylor College of Medicine, Houston, Texas
77-year-old woman presented with abdominal
A pain and early satiety. Computed tomography
of the abdomen (Figure A) showed a 6-cm submucosal
mass (white arrow) on a stalk (black arrow) arising
from the gastric fundus as well as several benign-
appearing liver lesions. Esophagogastroduodenoscopy
(Figure B) demonstrated the same non-friable, non-
obstructing gastric mass (white arrow) and its stalk
(black arrow). While biopsy results were pending, the
patient presented to the emergency department with
acutely worsening abdominal pain, nausea, vomiting,
and jaundice. Laboratory evaluation was significant
for the following: alanine aminotransferase 83 U/L,
aspartate aminotransferase 117 U/L, total bilirubin
4 mg/dL, and lipase 5315 U/L. Computed tomography
imaging (Figure C) showed that the aforementioned
mass had prolapsed into the duodenum (white arrow)
and obstructed the ampulla of Vater, resulting in dila-
tion of the common bile duct (white arrowhead),
pancreatic duct (black arrow), and gallbladder. The
mass was resected surgically, and microscopic evalua-
tion (Figure D) revealed a low-grade spindle-cell
neoplasm expressing CD117 (KIT), which is consistent
with a gastrointestinal stromal tumor (GIST). The
patient recovered well from surgery. Her serum bili-
rubin and lipase levels normalized, and postoperative
imaging showed resolution of the pancreatobiliary
ductal dilation. Because this GIST carried a low
(<5%) risk for recurrence on the basis of its size
(5–10 cm), location (stomach), and low mitotic rate
(5 mitoses/50 high-power field), we did not recom-
mend any adjuvant therapy.1
Comprising fewer than 1% of all gastrointestinal
tumors, GISTs are intramucosal spindle-cell neoplasms
that can arise throughout the gastrointestinal tract
but are most commonly found in the stomach. Although
they are frequently discovered incidentally, GISTs
may cause early satiety, bloating, bleeding, pain, or
frank bowel obstruction. Our patient presented with
pancreatitis and biliary obstruction (manifested by
elevated serum lipase and bilirubin levels and a
radiographic “double-duct” sign) because of a pro-
lapsed GIST obstructing the ampulla of Vater. Although
gastric GISTs or polyps may infrequently prolapse
through the pylorus into the duodenum, to our
knowledge there are only 2 published case reports of
gastric GIST causing pancreatitis2,3 and no published
reports of gastric GIST causing both pancreatitis and
biliary obstruction. After resection of a GIST, the
consulting oncologist can assess recurrence risk on the
basis of tumor size, mitotic rate, and anatomic location1
and, in turn, determine whether to recommend imati-
nib, which has been shown to improve recurrence-free
survival in patients with resected intermediate or high-
risk GIST.4
References
1. Miettinen M, Lasota J. Gastrointestinal stromal tumors: pathol-
ogy and prognosis at different sites. Semin Diagn Pathol 2006;
23:70–83.
2. Senadhi V, Arora D, Jani N. Gastrointestinal stromal tumor
(GIST) presenting with acute pancreatitis. Endoscopy 2011;
43(Suppl 2 UCTN):E76.
Clinical Gastroenterology and Hepatology 2015;13:e35–e36
ELECTRONIC IMAGE OF THE MONTH, continued
3. Jones O, Monk D, Balling T, et al. Acute pancreatitis secondary to a
prolapsed gastric fundal GIST. Int J Surg Case Rep 2012;3:82–85. Conflicts of interest
The authors disclose no conflicts.
4. Dematteo RP, Ballman KV, Antonescu CR, et al. Adjuvant
imatinib mesylate after resection of localised, primary gastroin-
© 2015 by the AGA Institute
testinal stromal tumour: a randomised, double-blind, placebo- 1542-3565/$36.00
controlled trial. Lancet 2009;373:1097. http://dx.doi.org/10.1016/j.cgh.2014.09.037

e36