Men have black stool for 4 days without inducement. You may not have seen this kind of acute gastrointestinal bleeding

Only for medical professionals to read for reference.
During clinical work, there are especially many patients with gastrointestinal bleeding.
Today I will show you a special case.

Case characteristics Liu, male, 58 years old.

The main complaint was "black stool for 4 days" and was admitted to the hospital on February 19, 2021 06:20:25.

The patient had melena 4 days ago without any obvious cause.
Once a day, the specific amount is unclear.
There is no obvious abdominal pain, bloating, acid reflux, heartburn, nausea, vomiting and other discomforts.
Oral medication at the local clinic has no obvious effect.

This morning, she developed dizziness, nausea, no vomiting, hematemesis and other discomforts, so she came to the emergency department of our hospital and was admitted to the hospital with "acute gastrointestinal bleeding".

Previous physical fitness, no history of hypertension, diabetes, coronary heart disease, tuberculosis, hepatitis, no history of blood transfusion and blood donation, no history of drug and food allergies, history of vaccination according to the local area.

Body temperature: 36.
4°C, pulse rate: 90 beats/minute, breathing: 20 beats/minute, blood pressure: 106/72mmHg, weight: 80kg.

Physical examination: Consciousness, good spirits, no abnormalities on cardiopulmonary auscultation, soft abdomen, upper abdominal tenderness, no rebound pain, normal bowel sounds, and no edema in both lower limbs.

Blood routine (2021-02-19) results: white blood cells (4.
9×109/L); percentage of neutrophils (67.
8%); neutrophils (3.
34×109/L); red blood cells (2.
97×1012/L) ; Hemoglobin (90g/L); platelets (144×109/L).

Admission diagnosis: 1.
Acute gastrointestinal bleeding; 2.
Mild anemia.

After admission, the relevant examinations were perfected, fasting, acid suppression, fluid replacement, hemostasis, and other treatments were given.
Gastroscopy on the day of admission was 1.
Erythematous exudative gastritis with erosion; 2.
Xanthoma of the gastric antrum, no active bleeding. On February 21, the blood test showed that the hemoglobin dropped to 65g/L.
Considering active bleeding, the colonoscopy on February 22 was normal.

Considering the bleeding in the middle gastrointestinal tract, and there is still active bleeding, the next step is to perform capsule endoscopy or abdominal CT.

Capsule endoscopy, not to mention the cost, even 50,000 photos can not be read in a few hours.

I communicated with my family, and after discussing with them, they agreed to perform a CT examination of the abdomen.
I really found the problem.

A CT examination of the abdomen was performed on February 22: 1.
The lower abdominal cavity was occupied with a small amount of fluid in the abdominal cavity, considering the source of the small intestine; 2.
Prostatic hyperplasia with calcification; 3.
The right lung cord lesion as shown.

Fortunately, if capsule endoscopy is performed, the capsule may not be able to pass the lesion smoothly.

On the one hand, a gastrointestinal hepatobiliary surgeon is invited for consultation, on the other hand, an enhanced CT examination of the upper abdomen is performed, and the consultant recommends surgical treatment.

On February 23, an enhanced CT scan of the abdomen was performed, and the lower abdominal cavity was occupied.
The small intestine was considered and the stromal tumor was considered.

He was transferred to surgery on February 23 and underwent surgical treatment in the afternoon of the same day.

Intraoperative brief procedure: A small intestine tumor is seen in the lower abdomen, about 10cm×8cm, with local vascular bundles connected to the greater omentum, and the lower part adheres to the sigmoid colon.
Ligation and cuts off the vascular bundles attached to the greater omentum.
The median incision is about 8cm in length.
Cut the skin and subcutaneous layers into the abdomen.

Abdominal exploration: light red ascites in the abdominal cavity, separate the adhesion of the small intestine and the sigmoid colon, cut the corresponding mesentery along the pre-resection of the small intestine, completely stop bleeding, cut the intestinal tube about 20cm, and suture the mesenteric hiatus intermittently to prevent internal hernia.

Postoperative pathology: (small bowel mass) Resection specimen: submucosal spindle cell tumor with partial degeneration and necrosis, considered as 1.
Gastrointestinal stromal tumor (GIST) with partial cystic degeneration, the size of the mass is 7cm×5.
5 cm×4cm, to be further diagnosed by immunohistochemical markers; 2.
(periintestinal lymph nodes) 2 lymph nodes showed reactive hyperplasia changes. Immunohistochemistry: The results of immunohistochemistry showed: CD117 (+), CD34 (vascular +), CKpan (-), Desmin (-), DOG-1 (+), HMW (Caldesmon) (focus +), Ki- 67 (hot spot +5%), MSA (-), S-100 (-), SMA (focal weak +), Vim (+).

(Small intestinal mass) Resection specimen: Submucosal spindle cell tumor with partial degeneration, necrosis, cystic change, immunohistochemical marker results support: gastrointestinal stromal tumor (GIST), mitotic figures <5/50HPF, combined tumor The size of the object is 7cm×5.
5cm×4cm, which meets the high risk.

Imatinib was added and he got better and was discharged from the hospital.

A clear diagnosis was hemorrhage of small intestinal stromal tumor.

Recognizing gastrointestinal stromal tumors GIST (gastrointestinal stromal tumor, GIST) mostly occurs in the stomach, duodenum, and small intestine, and is a group of the most common mesenchymal tumors that originate independently from the gastrointestinal tract.

Traditional imaging methods, such as endoscopy and barium contrast, are difficult to observe the submucosal conditions, and the diagnosis rate is low.

It is also difficult to distinguish between leiomyomas and nerve sheath tumors under light microscope by histopathological examination.

In recent years, with the widespread use of multi-slice spiral CT (MSCT) and immunohistochemistry in clinical practice, the accuracy of GIST diagnosis has been improved.

GIST has no specific clinical manifestations.
It mainly manifests as abdominal masses, abdominal pain, gastrointestinal bleeding, etc.
The imaging is clinically significant if the tumor is large or has infiltration or metastasis.

Histopathology GIST tumor cells have the characteristics of variable morphology.

According to the Chinese Consensus on the Diagnosis and Treatment of Gastrointestinal Stromal Tumors (2013 edition), histologically, GIST is divided into three major categories based on the morphology of tumor cells: spindle cell type (70%), epithelioid cell type (20%) and Spindle cell-epithelial-like cell mixed type (10%).

Tumor cells are mostly arranged in bundles and fences, with vacuoles around the nucleus, similar to leiomyomas or schwannomas, and a few are epithelial-like cells.

Diagnosis by light microscope is difficult to distinguish from neurogenic tumors and gastrointestinal smooth muscle tumors.

The pathogenesis of GIST is the functional mutation of the proto-oncogene C-kit and the mutation of PDGFRA (platelet-derived growth factor receptor), which activates tyrosine kinase, promotes cell proliferation and differentiation out of control, and forms tumors.

As long as the morphology meets the characteristics of GIST, and the immunohistochemical CD117, CD34 and DOG1 are positive, it can be diagnosed as GIST.

CDll7 is on the cell surface and cytoplasm of GIST.
Complete removal of the tumor is the key to improving the efficacy.

GIST can cause compression and compression to peripheral blood vessels, but it rarely causes envelopment and invasion of peripheral blood vessels.

Since GIST mainly grows out of the cavity, intestinal obstruction rarely occurs clinically.

The latest development in the treatment of GIST at this stage is the combined treatment of imatinib and surgery.

This combination can significantly improve the therapeutic effect and prolong survival.

Lessons learned: 1.
For patients with gastrointestinal bleeding, the general order of examination is gastroscopy, colonoscopy, and capsule endoscopy.
It is recommended to complete the abdominal CT examination before capsule endoscopy to find out whether there are space-occupying lesions.

2.
Patients with melena generally consider upper gastrointestinal bleeding.
Gastroscopy can make a clear diagnosis.
There are relatively few small bowel lesions.
However, recently the author has found several cases of bleeding caused by small intestine occupation, so the gastroscope can not make a clear diagnosis.
Don't worry, it is recommended to further improve related inspections.

Reference source: [1] CSCO Gastrointestinal Stromal Tumor Expert Committee.
Consensus on the diagnosis and treatment of gastrointestinal tumors in China (2013 edition) [J].
Journal of Clinical Oncology, 2013, 18(11): 1025-1031.
[2] Wang Jueji, Ding Kefeng, Chen Lirong, et al.
Diagnosis and clinicopathological characteristics analysis of 32 cases of gastrointestinal stromal tumors[J].
Chinese Journal of General Surgery, 2004, 19(6): 340-342.