Today the case of gastrointestinal bleeding presented by our colleague from outcampus UKM Master's candidate, Dr Rajaie, who is currently doing his Vascular rotation in PPUKM.
Our specialists and consultants for the sessions were:
- Prof Norlia
- AP Datuk Dr Ismail Sagap
- Ms Saladina
- Mr Razrim
- Mr Mustaffa
- Mr Khairul
- Mr Ikhwan (HPB Fellow)
- Mr Auzama (Colorectal Fellow).
Attendance: 75% (Master's Students in General Surgery rotation)
Slides: click here for the Microsoft Power Point Slide download
Rajaie started his presentation with chief complaint of his case (melaena) and threw couple of questions to medical students.
What relevant further history would you ask to the patient?
Hematemesis, anaemia symptoms, constitutional symptoms, previous similar presentation
What other relevant medication/drugs history would be relevant to the case?
Patient was on steroid (risk factor for upper GI bleeding).
Presentation was continued with physical examination findings of a centrally lobulated mobile mass palpable in the abdomen with no palpable hepatomegaly or splenomegaly. OGDS revealed a normal findings and followed by colonoscopy which showed an intraluminal altered blood with no stigmata of recent hemorrhage over the bowel mucosa.
The case was presented up until the management of the patient, with Q&A sessions headed by AP Datuk Dr Ismail Sagap started.
What would you do in this case, if patient in presented with shock (grade 2), persistent tachycardia despite adequate fluid resuscitation, symptomatic of anemia with Hb level 7.9 g/dL, is having fresh melaena, with a palpable mobile abdominal mass? (AP Datuk Dr Ismail Sagap)
In cases like the presenting lady, it is most likely a bleeding small bowel tumor, with probaility of a bleeding small bowel GIST as high as 70-80%.It is likely to be a resectable tumor as evidence by the mobility of the tumor on clinical examination. A laparotomy would be a choice of management plan to control the bleeding and to remove the tumor.
What is the role of CT scan in this case (acute gastrointestinal bleed)? (AP Datuk Dr Ismail Sagap)
CT scan abdomen with angiogram will onlt delay the definitive treatment in this case. A selective mesenteric angiogram may play a role. However in this case, as evidence by patient in shock may necessitate the surgery rather than delaying the surgery with a CT scan.
Case was further discussed and diagnosis of BLEEDING TUMOR was made. Patient went on to proceed with laparotomy. AP Datuk Dr Ismail Sagap commented on the diagnosis made need to be precise and specific, i.e: not bleeding tumor, it should had been Bleeding Small Intestinal Tumor.
Why laparotomy? (AP Datuk Dr Ismail Sagap)
At that time of managing the patient, the valid argument was, a CT scan will only delay a definitive management. However, UNLESS the decision for a CT scan is going to impact the decision of surgery significantly in the outcome (i.e. no need of surgery), then the decision for laparotomy is the best choice.
At that time of managing the patient, the valid argument was, a CT scan will only delay a definitive management. However, UNLESS the decision for a CT scan is going to impact the decision of surgery significantly in the outcome (i.e. no need of surgery), then the decision for laparotomy is the best choice.
How do you counsel patient for surgery? (Mr Mustaffa)
We need to explained the need and reason for the surgery to be done. Patient will need to be informed of the risk of stoma, possible anastomosis leak (if our diagnosis is correct).
If there is possibility of our diagnosis to be wrong, we are to consult patient of possibility on the referral to the appropriate team and still proceed with necessary procedure.
How do you describe this lesion (image as in presentation)? (AP Datuk Dr Ismail Sagap)
This image is the intra-operative finding of what appears to be like small bowel stuck to a lobulated tumor with capsular breach.
What is the possible diagnosis (from the photo)?
GIST. Why? It is an extra-luminal tumor.
What is your differential diagnosis?
Lymphoma (mesenteric), secondary (i.e mesenteric secondary tumor, from colon - usually inside mesentery, and size is smaller)
Lymphoma (mesenteric), secondary (i.e mesenteric secondary tumor, from colon - usually inside mesentery, and size is smaller)
If i am to take a photo, what else would I include? (AP Datuk Dr Ismail Sagap)
Lift up the tumor before taking the photo, this will tell us about intra or extraperitoneal tumor.
Is it dangerous if we rupture the tumor? (AP Datuk Dr Ismail Sagap)
Will it cause recurrence? Yes, it can cause seedlings.
Surgery, how to resect the tumor? (AP Datuk Dr Ismail Sagap)
Principle for resection of small bowel tumor is to do en bloc resection, with margin of 5cm to achieve oncologic resection.
Principle for resection of small bowel tumor is to do en bloc resection, with margin of 5cm to achieve oncologic resection.
If this is GIST , (referring to the image) is it a malignant lesion? (AP Datuk Dr Ismail Sagap)
Yes
What would you like to see in the HPE? (Dr Rajaie)
Answer is in the slide.
HPE report as per below (in summary)
HPE report as per below (in summary)
Malignant spindle cells in storiform pattern.
Spindle cell: nerve/smooth muscle origin.
Immunohistochemical staining is Positive for:
CD117
Vimentin
CD34
DOG-1
CD117
Vimentin
CD34
DOG-1
Negative for
SMA
Desmin
S100
S100
Mitotic count: 7/50 hpf.
What does all these mean? (AP Datuk Dr Ismail Sagap)
GIST tumor.
Which information in the HPE will inform you that this is a malignancy? (AP Datuk Dr Ismail Sagap)
Mitotoc count of >5/hpf.
Which information in the HPE will inform you that this is a malignancy? (AP Datuk Dr Ismail Sagap)
Mitotoc count of >5/hpf.
Size of tumor >5cm
Nucleus criteria.
The case HPE impression was Malignant GIST of small bowel.
Why the word "malignant" is important? (AP Datuk Dr Ismail Sagap)
Management is totally different. In case of a malignancy, the mainstay of treatment is oncological resection and followed by chemotherapy (in this case it was Glivec).
The session continued with comments from AP Datuk Dr Ismail Sagap with regards to registrars answering style of alway trying to give a "vague " terminology.
Prognosis of the case? (AP Datuk Dr Ismail Sagap)
GIST has a high risk of recurrence and well known to be notorious in local recurrence.
GIST has a high risk of recurrence and well known to be notorious in local recurrence.
Prognosis will be based on:
- Tumor size
- Mitotic index
- Site of origin
AP Datuk Dr Ismail Sagap suggest for the masters candidate to memorize the immunohistochemistry algorithm in diagnosing GIST. This algorithm was prepared by Dr Rajaie in the slide.
Why they use "recurrence free survival" rather than "overall survival?" - (AP Datuk Dr Ismail Sagap)
Because it is a tumor with borderline malignancy. Overall survival is not being used because usually patients with GIST has a very long overall survival. So, the recurrence free survival has become a better measurement index for GIST to project the prognosis index.
How many percent of small bowel tumor is GIST? (AP Datuk Dr Ismail Sagap)
Surveillence of the GIST patients? (AP Datuk Dr Ismail Sagap)
Based on current consensus, it is advised for CT scan to be done every 6 month (for patients with malinant GIST on chemotherapy i.e. Glivec) - Dr Rajaie
The session ended following a very fruitful discussion and Q&A session. Thank you to Dr Rajaie for a very good case being discussed and a good review for an overview of the disease. Hope we can always continue to have great sessions of RECAP in the future.
Happy learning.
QUOTE OF THE DAY:
“Lack of direction, not lack of time, is the problem. We all have twenty-four hour days.” - Zig Ziglar
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