Endoscopic hemostasis of a bleeding gastric gastrointestinal stromal tumor (GIST) with endoloop placement.

INTRODUCTION

Gastrointestinal bleeding due to gastric neoplasia is difficult to manage and may provoke dramatic situations. For the most part, therapeutic endoscopic methods provide only temporary success in controlling bleeding. Often, a poor clinical condition and an advanced stage of the neoplastic disease mean these patients will receive exclusively palliative clinical care. Hence, surgical procedures are often contraindicated, either due to lack of clinical conditions or the increased mortality resulting from surgical trauma. In such cases, alternative endoscopic techniques have been described as minimally invasive means of controlling tumor-induced bleeding.

CASE REPORT

A 79 year-old man with gastric GIST, receiving Imatinib for the presence of multiple hepatic (Figure 1), pulmonary and bone metastases, was admitted to the Cancer Institute of the University of São Paulo Medical School,São Paulo, SP, Brazil after presenting massive hematemesis, followed by syncope.

FIGURE 1

Multiple hepatic metastases

An upper gastrointestinal endoscopy was indicated. The exam revealed fresh blood in the gastric chamber and a 4 cm submucosal ulcerated lesion, partially covered with adherent clots in the cardia region. Since there was no ongoing bleeding, endoscopic therapy was not performed at that time. However, after multidisciplinary discussion, it was decided to attempt endoscopic hemostasis due to the high risk involved in using anesthesia to perform surgical resection. An endoloop was placed at the base of the lesion in a retroflexed position (Figure 2).

FIGURE 2

Endoscopic retroflexion: bleeding GIST and endoloop placement

One week later, an endoscopic review exam was performed, demonstrating the successful hemostastic procedure (Figure 3).

FIGURE 3

Endoscopic follow-up: GIST looped, with ischaemic appearance and necrosis

The patient was then referred to and followed by the palliative care group and died two months later, without further bleeding.

DISCUSSION

Endoscopic hemostasis of tumoral lesions is a challenging situation, since no endoscopic therapy has been proved to be superior[3]. Choice of therapy will be dictated by the tumor's appearance and the personal experience of the endoscopist. Reports show that hemoclips have been applied in both successful[2] and failed[4] attempts to achieve hemostasis. In the present case, the tumor appeared to be friable and an attempt to apply hemoclips could have led to mucosal tearing and recurrent bleeding. Endoloop ligation of such lesions has been described to treat bleeding tumors and also to resect lesions in patients deemed non-surgical candidates, through ischemic necrosis (loop-and-let-go)[1]. Although the surgical approach is considered the treatment of choice for such lesions, the endoloop technique is a useful, feasible, cheap and safe alternative for patients considered unsuitable for surgery or as a temporary measure to stabilize patients before the surgical treatment.