Section 2 of 4
Case presentation
Ala Hamid Ali Suliman, Aaliyah Kheruwala, Ahmad Barbour, Sara Eltayeb, and Ahmed Khassouan · about 4 minutes
A male with a history of hypertension and hyperlipidemia experienced two episodes of upper GI bleeding separated by seven years. His initial presentation occurred in 2017 with a Dieulafoy’s lesion, while his recurrent presentation in 2024, at the age of 71 years, led to the diagnosis of a gastric GIST.
In 2017, he presented to the emergency department with hematemesis, melena, fatigue, and hemodynamic instability. Laboratory investigations revealed severe anemia with a hemoglobin level of 7.0 g/dL, requiring blood transfusion (Table 1). Upper GI endoscopy demonstrated a large adherent blood clot within the gastric fundus, obscuring visualization of the underlying lesion (Figure 1). Following clot removal, an isolated protruding vessel overlying normal-appearing mucosa was identified, consistent with a Dieulafoy lesion (Figure 2). Endoscopic hemostasis was successfully achieved with hemoclip placement. The patient remained clinically stable following the procedure and was discharged home.
Parameter | 2017 presentation | 2024 presentation | Reference range | Interpretation
Hemoglobin (g/dL) | 7.0 | 7.8 | 13.0-17.0 | Severe anemia
Hematocrit (%) | 21.2 | 21.9 | 40-50 | Decreased
RBC count (×10¹²/L) | 2.23 | 2.34 | 4.50-5.90 | Decreased
MCV (fL) | 95.2 | 93.8 | 80.0-100.0 | Normocytic
MCH (pg) | 31.5 | 33.5 | 27.0-33.0 | Normal; mildly elevated in 2024
RDW (%) | 14.1 | 13.3 | 11.5-14.5 | Within normal limits
White blood cell count (×10⁹/L) | 16.0 | 9.9 | 4.0-11.0 | Elevated in 2017; normal in 2024
Platelet count (×10⁹/L) | 110 | 196 | 150-400 | Mild thrombocytopenia in 2017; normal in 2024
Urea (mg/dL) | 23 | 18 | 15-40 | Within normal limits
Creatinine (mg/dL) | 0.50 | 0.83 | 0.70-1.30 | Normal renal function
INR | 1.25 | 1.14 | 0.80-1.20 | Mildly elevated in 2017; normal in 2024
Figure 1: Large blood clot covering the fundus.
Figure 2: Dieulafoy's lesion in the fundus, hemoclip applied.
In 2024, the patient re-presented with generalized fatigue, exertional dyspnea, dizziness, near-syncope, and melena of four days’ duration. He denied the use of nonsteroidal anti-inflammatory drugs, antiplatelet agents, or anticoagulants. On examination, he appeared pale and demonstrated orthostatic hypotension. Laboratory investigations again revealed significant anemia with a hemoglobin level of 7.8 g/dL, necessitating transfusion of two units of packed red blood cells.
Upper GI endoscopy revealed a large ulcerated submucosal mass measuring approximately 6 cm in the gastric fundus, located more than 5 cm distal to the cardia (Figure 3). A small clean-based ulcer overlying the lesion was identified without evidence of active bleeding. No endoscopic hemostatic intervention was required, and the patient was managed conservatively with intravenous pantoprazole.
Figure 3: A 6 cm submucosal mass in the fundus, more than 5 cm away from the cardia.
Endoscopic ultrasound demonstrated a mass arising from the fourth layer of the gastric wall. Fine-needle aspiration confirmed a low-grade mixed-type GIST. Contrast-enhanced computed tomography of the abdomen demonstrated an enhancing endoluminal gastric mass without evidence of metastatic disease.
Following multidisciplinary team discussion, the patient underwent laparoscopic wedge resection. Gross examination demonstrated a gray-white solid tumor with a firm consistency and no evidence of necrosis. Histopathological examination revealed a spindle-cell neoplasm composed of fascicles of bland spindle cells (Figure 4). Higher-power examination demonstrated intersecting bundles of spindle cells with elongated nuclei, inconspicuous nucleoli, and faintly eosinophilic cytoplasm (Figure 5). Immunohistochemical staining was positive for DOG1 and CD117 (Figures 6, 7), supporting the diagnosis of GIST.
Figure 4: Low-power view (4×) showing a spindle cell lesion.
Figure 5: Medium-power view (20×) showing intersecting bundles of bland spindle cells with elongated nuclei, inconspicuous nucleoli, and faintly eosinophilic cytoplasm.
Figure 6: Medium-power view (20×) demonstrating DOG1-positive immunostaining.
Figure 7: Medium-power view (20×) demonstrating CD117-positive immunostaining.
The resected specimen measured 6.5 × 5.5 × 4.5 cm. Final histopathological analysis confirmed a mixed-type GIST, G1, low risk, pT3, with a mitotic rate of 3 mitoses per 5 mm². Surgical margins were negative for tumor involvement.
The postoperative course was uneventful. The patient continued pantoprazole therapy and was discharged in stable condition.