1. 우상복부 불편감을 주소로 내원한 72세 남자 흑색변을 주소로 내원한 39세 여자
홍성노, 김정환, 성인경, 박형석, 심찬섭
건국대학교병원 소화기병센터

2. Case1 (72/M) Chief Complaint : RUQ discomfort Present illness
Onset: 2 months ago
Present illness
2달 전부터 우상복부가 뻐근하고 거북한 증상 시작되어 OO병 원에서 EGD, 복부 CT검사 시행
Imp: r/o liver metastasis d/t colon cancer
Past History
DM/HTN/Hepatitis/Tb (-/-/-/+)
Current medication : BPH medication

3. Physical Examination Laboratory data V/S 106/52-64-20-36.4
Anicteric sclera
Abdomen : DT/RT (-/-) / RUQ discomfort (+)
no palpable mass
Laboratory data
CBC: 7, / k
T.Bil/AST/ALT/ALP 0.8/47/81/564
AFP 3.14

4. Outside CT / Colonoscopy
Mid A colon, 0.6cm, O-Is type
Tubular adenoma

5. Single Balloon Enteroscopy (oral route)

6. Biopsy results Pathology Duodenum, 4th, fiberscopic biopsy:
Gastrointestinal stromal tumor
[SPECIAL & IMMUNOHISTOCHEMICAL STAIN]
CD34 : positive
CD117(=C-kit) : positive
Desmin : negative
S-100 : negative
SMA : positive
C-kit (+)

7. Follow-up
6.7 X 5.6 cm
5.2 X 3 cm
Glivec® 400mg q.d. for 2month

8. Final Diagnosis GIST in Duodenal 4th portion
with Massive Liver Metastasis
- Diagnosed with Single-Balloon Enterscopy
- Treated with Imatinib (Glivec®)

9. Case 2 (39/F) Chief Complaint : Melena Present illness
Onset: 10 days ago (5 times)
Present illness
10일전부터 시작된 5차례 정도의 Melena로 OO 병원 내원
Hb 6.8 g/dl
EGD (duodenal 2nd portion 관찰 포함), Colonoscopy
: 출혈 원인 찾지 못함
Small bowel bleeding 의심되어 Further evaluation 위해 전원

10. Past History Review of system DM/HTN/Hepatitis/Tb (-/-/-/-)
Current medication : none
Review of system
Easy Fatigability (+) / Dizziness (+)
Weight loss (-)
Anorexia / Nausea / Vomiting (-/-/-)
Diarrhea / Constipation (-/-)
Abdominal pain / discomfort (-/-)

11. Initial Laboratory Data
Physical examination
V/S 103/
Anicteric sclerae, Pale conjunctivae
Abdomen
Soft and flat, Normoactive bowel sound
DT/RT(-/-) , No palpable mass
Initial Laboratory Data
CBC 3, / K
pRBC 2 pint transfusion  Hb/Hct 8.7/25.6
PT(INR)/aPTT 13.0sec(1.01)/32.6sec
BUN/Cr 13.0/0.8
T.Bil/AST/ALT/ALP 0.2/19/17/52

12. CT Angio + GI Bleeding 3D
Arterial Phase
Portal Phase

13. EGD with an attached transparent hood
2nd Look EGD
EGD with an attached transparent hood

14. Oblique-viewing Echoendoscope

15. Operation Op. name : Open wedge resection Pathology
Gastrointestinal stromal tumor, low risk (by Fletcher,2007)
1) size of tumor: 2.5 x 2.3 x 2.0 cm
2) mitotic activity: 2/50 HPF
3) resection margin: very close to resection margin
Special Immunochemical Stain
CD117(=C-kit) : positive / CD34 : positive
S-100 : negative / SMA : positive
CD117(C-kit)

16. Final Diagnosis GIST, Low risk, in Duodenal 2nd portion
- Diagnosed with Oblique viewing endoscope
- Treated with Wedge resection

17. Duodenal GIST Prevalence Distribution Clinical presentations Treatment
Relatively small subset of overall GI GIST: 3–5%
Distribution
2nd portion > 3rd portion > 4th portion > 1st portion
Clinical presentations
Highly variable according to size and mucosal ulceration
GI bleeding, epigastric pain, palpable mass, obstruction
Treatment
Surgical resection
Imatinib (Glivec®)

18. Duodenal GIST Gross finding Diagnosis Endoscopy with biopsy CT, MRI
Luminal protruding subepithelial lesion with centrally ulcerated umbilication
Extend from submucosal or muscularis propria to external aspects (about 1/3 duodenal GISTs Miettinen M et al. Am J Surg Pathol 2003)
Diagnosis
Endoscopy with biopsy
1st, 2nd portion : EGD
can be missed the tumor located in anti-mesenteric boarder
3rd, 4th portion : (Push) Enteroscopy
CT, MRI