The British Journal of Radiology, 75 (2002), 987–989 E 2002 The British Institute of Radiology
Gastroduodenal intussusception of a gastrointestinal
K S CROWTHER, MBChB, 1L WYLD, MBChB, PhD, FRCS, 2Q YAMANI, BSc, MRCP, FRCR and
G JACOB, MC BCH, MCH, FRCS
Departments of 1Surgery and 2Radiology, Doncaster Royal Inﬁrmary, Armthorpe Road, Doncaster DN2 5LT,
Abstract. Gastrointestinal stromal tumours (GISTs), previously termed leiomyomas and
leiomyosarcomas are relatively common tumours of the gastrointestinal tract, most commonly
found in the stomach. Most GISTs are asymptomatic but may cause abdominal pain or bleeding
from ulceration of the overlying mucosa. A rare case of gastroduodenal intussusception of a large
gastric stromal tumour, which presented with intermittent abdominal pain and gastric outlet
obstruction, is reported. Pre-operative diagnosis was made on abdominal CT and conﬁrmed at
laparotomy. Pre-operative diagnostic difﬁculties and management are discussed.
Gastrointestinal stromal tumours (GISTs) are A very rare complication of GISTs is gastro-
relatively common tumours of the stomach, duodenal intussusception caused by prolapse of
occurring in up to 46% of stomachs in some the tumour and subsequent invagination of a
post mortem series . These tumours were portion or the full thickness of the gastric wall
previously referred to as leiomyomas and leio- into the duodenum [6–8]. This may present with
myosarcomas, but have recently been reclassiﬁed intermittent vague epigastric pain or as an acute
as they arise from undifferentiated stromal gastrointestinal emergency with severe sudden
ﬁbroblasts rather than mature smooth muscle pain, shock and intractable vomiting. Inter-
cells [2, 3]. GISTs can range in size from under mittent symptoms due to recurrent, spontaneously
0.5 cm diameter to 30 cm diameter. Three-quarters reducible intussusceptions have been reported
of these tumours are benign, but as size increases [7, 8]. An epigastric mass may be palpated on
the risk of malignancy rises such that 60% of physical examination.
tumours over 10 cm are malignant (usually Endoscopy, ultrasound and barium studies
determined by the histological presence of more have previously been used to demonstrate this
than ﬁve mitotic ﬁgures per 10 high power ﬁelds). rare complication of a GIST but, until this case,
Age is also a relevant factor, with GISTs common it has never been demonstrated by CT.
in those between 50 and 60 years of age, and less
common in those aged 40 years or younger. The Case report
incidence of malignancy is higher in the younger
age group. A 59-year-old female presented with a 1-year
The majority of GISTs are asymptomatic, with history of indigestion and a 3-week history of
a large proportion being found incidentally intermittent severe epigastric pain, premature
at autopsy or during other surgical procedures. fullness and vomiting bile-stained ﬂuid and
Macroscopically GISTs are smooth submucosal undigested food. Between these episodes the
projections into the stomach lumen. Ulceration patient was well. On examination, the patient
of the apical mucosa may occur resulting in was mildly tender in the epigastrium but no mass
abdominal pain and bleeding, which is present was palpable. All haematological and biochemical
in up to 50% of benign tumours and 85% of indices were normal. An upper gastrointestinal
malignant tumours . Less commonly, patients endoscopy performed at the referring hospital was
may complain of weight loss, a palpable mass, reported as showing a dilated stomach, pylorus
early satiety, dysphagia and vomiting . and proximal duodenum, thought to be consistent
with small bowel obstruction. There was no evi-
Received 13 December 2001 and in revised form 24 June dence of stromal tumour. Abdominal ultrasound
2002, accepted 5 July 2002. revealed a dilated stomach, despite fasting, and
Address correspondence to Mr G Jacob, MC BCH, an unusual echo pattern in the region of the
MCH, FRCS. duodenum, suggesting gastric outﬂow or duodenal
The British Journal of Radiology, December 2002 987
K S Crowther, L Wyld, Q Yamani and G Jacob
Figure 3. CT section below the level of Figure 2. L,
gastrointestinal stromal tumour containing low den-
sity areas consistent with fat in the lesion; G, ﬂuid in
body of stomach.
Figure 1. Barium meal demonstrating a dilated
stomach with an intramural mass lesion between
the ﬁrst and second parts of the duodenum. At laparotomy the gastric wall was distorted
and the third part of the duodenum was distended
obstruction. The barium meal also performed at by a hard mass. Manipulation of the mass deliv-
the referring hospital showed a dilated stomach ered it into the stomach and a simple gastrotomy
and an intramural mass lesion between the ﬁrst revealed a 7 cm stromal tumour on a long pedicle
and second parts of the duodenum (Figure 1). derived from the mucosa of the anterior gastric
This was reported as a possible tumour but in antrum. This had been intermittently prolapsing
retrospect demonstrated the intussusception. into the duodenum. The base of the tumour was
As a result of the discrepancy between these excised and the gastrotomy closed. There was no
initial investigations, CT was requested for further evidence of metastatic spread. The patient made
clariﬁcation. The examination conﬁrmed partial an uneventful post-operative recovery.
gastric outﬂow obstruction with a characteristic Histology conﬁrmed a smooth, 60 mm diameter
pattern of intussusception, four layers of bowel GIST with minimal nuclear pleomorphism, no
wall (‘‘partially inverted sock’’), at the pylorus. A necrosis and only one mitotic ﬁgure per 10 high
well deﬁned 5 cm diameter lesion, which con- power ﬁelds. Despite these good prognostic fea-
tained a rim of low density tissue compatible tures, the large size of the tumour placed it into a
with fat, was present in the region of the second borderline category for malignant potential.
part of the duodenum (Figure 2 and Figure 3).
Although extremely rare, a diagnosis of intussus-
ception of a GIST was suggested.
Gastroduodenal intussusception of a stromal
tumour of the stomach is a very rare cause of
duodenal obstruction, which unlike the most
common causes, periampullary and pancreatic
carcinomas, has a good prognosis. Pre-operative
diagnosis was difﬁcult to make and, although
suspected, was not conﬁrmed until laparotomy.
Previous cases of stromal tumours intussuscept-
ing into the duodenum have been demonstrated
on barium studies, ultrasound and endoscopy,
but this is the ﬁrst case demonstrated by CT. Due
to the CT ﬁndings, the patient went to theatre
and was operated on successfully. This unusual
case demonstrates the value of pre-operative
cross-sectional imaging, particularly when there
Figure 2. CT scan at the level of the intussusception.
G, ﬂuid in body of stomach; a, wall of the antrum; is a discrepancy between the initial ﬁrst line
P, pyloric wall; D1, ﬁrst part of the duodenum. investigations.
988 The British Journal of Radiology, December 2002
Case report: Gastroduodenal intussusception of a GIST
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