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INTRODUCTION:Gastrointestinal stromal tumors (GISTs) are a common mesenchymal tumor of the GI tract. Here we present a case of a 60-year-old male with a 33.5 × 27 cm GIST arising from the greater stomach curvature, increased in size from 18.1 × 13.4 cm in five months; an alarming growth rate for a tumor known to grow slowly.CASE DESCRIPTION/METHODS:60-year-old male with history of GIST and HTN presented to the hospital with abdominal pain and shortness of breath. Physical exam revealed decreased bowel sounds and diffuse tenderness to palpation in the right and left lower quadrants. Patient had previously been diagnosed with a 18.1 × 13.4 cm GIST 5 months prior, and was positive for CKIT (CD117) and DOG1, with 6 mitotic figures/21 HPFs (Figure 1). The patient was lost to follow up and never started on Imatinib. Over a span of five months, the necrotic mass had doubled in size with a repeat CT scan on admission showing a 33.5 × 27 cm GIST (Figures 2 and 3) arising from the greater stomach curvature, invading the left hepatic lobe and compressing the inferior vena cava (IVC). During this admission, he was also found to have bilateral pulmonary embolism, with large clot burden and right heart strain. An IVC filter would have been ideal for prevention of further clot migration, however the compression of the IVC by enlarging GIST prevented intervention. Patient was treated with heparin and started on Imatinib as an outpatient, patient is doing well and following with oncology.DISCUSSION:GISTs can be found in any part of the gastrointestinal tract, with predominance in the stomach. GISTs are often asymptomatic and diagnosed incidentally or they may present with nonspecific symptoms such as early satiety, abdominal pain, anemia, GI bleed or gastric outlet obstruction. Treatment options are dictated by risk of progression which is determined by size (≥3 cm), location, and mitotic count. [1] While the exact rate of tumor growth is unknown, studies have shown a range of 1.2 to 50.7% per annum [2]. On representation to the hospital five months after initial diagnosis, our patients’ mass had increased in size by 54% which surpasses documented growth rates. His mass also created significant compression and prevented integral placement of an IVC filter. While GIST tumors are traditionally thought to be slow growing tumors our case highlights the importance of earlier intervention in high-risk patients; metastatic and compressive complications could have been avoided for this patient had he returned for initial follow-up.

Sarcoidosis is a chronic granulomatous disease that is characterized by the formation of non-caseating granulomas, predominantly involving the lung and lymph nodes. Over the years, sarcoidosis has been associated with a high risk of malignancy. Solid pseudopapillary tumor of the pancreas is an uncommon pancreatic tumor with a 15% malignant potential. Ours is an interesting case of a 34-year-old patient who was found to have a pancreatic mass and incidental mediastinal lymphadenopathy on imaging, initially raising concern for metastatic pancreatic cancer. However, she was later diagnosed to have an isolated solid pseudopapillary tumor of the pancreas in association with concurrent sarcoidosis.

Hepatic portal venous air has traditionally been regarded as an ominous radiologic sign associated with high mortality and morbidity. Here we present a unique case of hepatic portal venous air from gastric emphysema due to transmural diffusion of air from mucosal breaks in the wall of the stomach as a result of repeated and forceful vomiting. Hepatic portal venous air seen in this setting is not indicative of grave intra abdominal pathology and usually resolves with conservative treatment. A 45 year old male with history of OSA comes to the emergency room with one day of nausea, multiple episodes of forceful vomiting, and associated epigastric pain. The abdominal pain was noted to get worse with movement. Social history is significant for daily marijuana use. Physical exam showed tenderness in the epigastric region and guarding on exam, but no signs of rebound tenderness or rigidity. CT abdomen and pelvis with contrast (Image 1,2, 3) showed emphysema in the gastric wall with air tracking through the portal venous vasculature to the periphery of the liver, but no pneumo-peritoneum or any evidence of full thickness gastric tear. Patient improved with anti-emetics and bowel rest. Air in the gastric wall can occur in emphysematous gastritis due to production of air by gas forming organisms or as seen in gastric emphysema from trauma, obstruction or from pulmonary causes. As opposed to emphysematous gastritis where patients are very sick with peritoneal abdominal signs, in gastric emphysema patients are usually hemodynamically stable and do not have signs of acute abdomen.[i] Prognosis is excellent and treatment is directed at treating the underlying cause. Patients with gastric emphysema may show signs of hepatic portal venous air due to absorption of gastric intramural air; however, unlike in cases of emphysematous gastritis this usually is not a sign of grave intra-abdominal pathology and can be managed conservatively as seen in our patient. 5. Misro A, Sheth H. Diagnostic dilemma of gastric intramural air. Annals of The Royal College of Surgeons of England. 2014;96(7):e11-e13.

Intussusception in the adult population is a rare occurrence; when seen in the adult patient it usually is seen in the setting of malignancy. Here we present an unusual case of a colonic lipoma masquerading as a cecal tumor and causing ileocolic intussusception. A 66-year-old female comes to the emergency room complaining of right sided, intermittent abdominal pain for the past 2-3 months and a few episodes of blood-tinged stool. Of note, the patient had a 15-pound weight loss. Physical exam showed mild, suprapubic tenderness. CT abdomen and pelvis with IV and oral contrast (Image 1 and 2) was concerning for ileocolic intussusception, with possible lipomatous mass acting as the nidus. Colonoscopy revealed a large, fungating cecal mass (Image 3), concerning for malignancy. The patient subsequently underwent laparoscopic right hemicolectomy. Pathology from the surgical specimen revealed a 6 cm mass consisting of mature adipocytes, consistent with a submucosal lipoma. Pathology also revealed ulceration, granulation, and abscess formation of the surface mucosa. Intussusception is the telescoping of a proximal segment of bowel into the lumen of a distal segment of bowel. Intussusception in the adult patient is unusual and when seen is often associated with malignancy in the GI tract. Gastrointestinal lipomas typically present asymptomatically; however as seen in our patient they can rarely act as a lead point for intussusception. Diagnosis of gastrointestinal lipomas can be difficult with imaging alone and they can often be mistaken for polyps or malignant lesions. Usually colonic lipomas are easy to diagnose on colonoscopy as characteristically soft, well-defined, yellowish masses. What is unusual about our case is that the endoscopic findings were highly suggestive of malignancy since the mass was ulcerated and had abscess formation on its surface. However, in hindsight the initial radiologic testing provided the correct diagnosis while the endoscopic findings were misleading. Our aim in presenting this case is to bring to light a rare cause of intussusception in the adult patient and highlight the importance of radiology in accurate diagnosis of large lipomas of the GI tract.