Repeated black stool for 1 year but can not find the source of bleeding? Notice that the disease will disguise.

Looking for the real culprit of occult gastrointestinal bleeding Clinical common lower gastrointestinal bleeding, according to the location of bleeding can be divided into large intestine bleeding and small intestine bleeding, in addition, adjacent organs of the intestinal malignant tumor infiltration or abscess rupture into the intestinal cavity can also cause bleeding.I hope that through today's case, we can recognize this rare disease, and we need to consider it in patients with occult gastrointestinal bleeding next time.55 year old female, repeated melena for 1 year, gastroscopy, colonoscopy, abdominal CT, still can not find a clear source of bleeding, repeated blood transfusion, iron supplement, but there is still hidden gastrointestinal bleeding, what is the reason? Let's find out this camouflage disease ~ case summary ■ female, 55 years old, repeated melena for 1 year transferred from the hospital.■ previous history of endometrial cancer underwent hysterectomy and bilateral oviduct oophorectomy, type 2 diabetes mellitus, dyslipidemia and obesity.■ after diagnosis and treatment, duodenal bulb inflammation was shown by external gastroscopy without signs of ulcer, bleeding or arteriovenous malformation; tubular adenoma of ascending colon was shown by colonoscopy, but there was no clear source of bleeding; abdominal and pelvic enhanced CT showed scar like changes, a small amount of perihepatic effusion and distal colonic diverticulosis after pelvic surgery, and no abnormality was found in the rest.after several times of blood transfusion and iron supplementation to correct anemia, the patient still had persistent fecal occult blood positive and refractory anemia (hemoglobin 58 g / L, hematocrit 19.6%).What's going on here? Referral to our hospital, repeated gastroscopy, colonoscopy, no positive findings.at last, a diverticulum like lesion of 1cm away from the pylorus was found by double balloon enteroscopy. The mucosa was intact without ulcer.is the bleeding caused by intestinal diverticulum? Routine examination of digestive tract hemorrhage of unknown etiology and ineffective medical treatment of malignant anemia, with abdominal exploration indications. The ileum mesentery was attached to the anterior abdominal wall, adjacent to a pelvic mass of about 12cm × 12cm × 3.5cm (Fig.1 and Fig.2). The abdominal wall was adhered. The ileum and pelvic mass were removed simultaneously.Figure 1: oral double balloon enteroscopy Figure 2: green indicates the connecting part of the mass and ileal diverticulum, and the blue color shows the edge of the mass. During the operation, rapid freezing shows 1.5cm ileal wall defect with serositis, which is directly connected with the bleeding center of pelvic mass. There is no tumor in the proximal, distal ileum and mesenteric margin. The other lesion edges, especially the areas attached to adjacent structures of pelvic mass, are not found The fragment of the sample cannot be evaluated.postoperative pathology showed spindle cell tumor (Fig. 3).Figure 3: histopathological examination showed that CD117 and dog1 were diffusely positive, while desmin, CD3 and S100 were negative, which was consistent with gastrointestinal stromal tumors (GIST) originated from small intestine.combined with history and pathology, rupture and bleeding of small intestinal stromal tumor were considered in the diagnosis.this case of stromal tumor & gt; 10cm, mitotic index & gt; 10 (index ≥ 5 is considered as high risk), the edge is difficult to assess, the patient is a high risk group of recurrence, imatinib 400mg / D, postoperative anemia was corrected, and then review every six months.at present, imatinib is well tolerated and has no signs of recurrence after 6 months and 1 year of imaging follow-up. The case was published in BMJ case rep [1].knows gastrointestinal cancer, gastrointestinal cancer, mostly in the elderly. GIST is the most common mesenchymal tumor in the gastrointestinal tract, which is originated from gastrointestinal mesenchymal stem cells. It accounts for 2.2% of the total gastrointestinal cancers. The incidence rate is about 1/10 1/10 2/10 [2]. The incidence rate of male and female patients is not significantly different, mostly in middle-aged and elderly patients, and rare in patients under the age of 40.gist can occur in any part of the whole gastrointestinal tract, but most often occurs in stomach (50% - 60%), small intestine (20% - 30%), colorectal (10% - 20%), esophagus (0% - 6%), rarely in mesentery, omentum and retroperitoneal cavity. its occult onset and lack of specificity in clinical features make early diagnosis difficult. ■ the most common gastrointestinal bleeding secondary to mucosal ulcer is outward growth. Gist is a group of mesenchymal tumors formed by undifferentiated epithelioid or pluripotent spindle cells. Its clinical manifestations depend on the size and location of the tumor. since gist is usually evolved from the outer muscular layer, it tends to grow outward and extend to the peritoneal cavity; over time, many larger gists grow to the lumen surface, resulting in mucosal ulcer and bleeding, so gastrointestinal bleeding secondary to mucosal ulcer is the most common. small tumors may be asymptomatic, and large tumors may have mass effects, including nausea, fullness, abdominal distension, obstruction and bleeding. When most gists are less than 5cm, they can grow significantly. ■ it is difficult to make a clear diagnosis before operation. Eus-fnagist comes from submucosa and is difficult to diagnose before operation. The combination of endoscopic ultrasonography, endoscopic ultrasonography fine needle aspiration (EUS-FNA) and abdominal CT can improve the detection rate and diagnostic rate, and the diagnosis depends on postoperative pathological examination. gist rarely has lymph node metastasis and can be completely resected, resulting in less probability of endovascular implantation [4]. Therefore, routine preoperative biopsy is not recommended. EUS-FNA is the first choice for those who need to make a definite diagnosis before operation. Table 1: list of examination methods of GISTs ■ prognosis is related to tumor size. UK clinical practice guide [5] recommends that GISTs with diameter less than 2cm are relatively safe and can be followed up annually through endoscopic ultrasonography. If progressive growth occurs, biopsy or resection can be performed again. according to the Asian consensus guidelines [6], gist diameter < 2cm and no signs of malignant transformation (irregular boundary, ulcer, bleeding, cystic change, necrosis or uneven echo) can be closely followed up, but the potential malignancy can not be ruled out. Patients should be informed of this possibility. Some patients were diagnosed as submucosal tumors and suspected to be post gist because of their fear of malignant transformation or metastasis Surgical resection is feasible; for gist of non gastric origin, surgery is recommended regardless of tumor size and shape. about 83% of GIST patients can undergo radical resection. Surgical open surgery is the main treatment because it can completely remove the tumor and avoid tumor rupture and dissemination. However, about 85% of patients are prone to metastasis and recurrence after operation, and the 5-year survival rate is only 50% - 65% [7]. in recent years, with the rapid development of laparoscopic and endoscopic technology, laparoscopic and endoscopic resection of gist has the advantages of short operation time, light postoperative pain, short hospital stay, low medical cost, and complete tumor resection, which is gradually replacing open surgery as the main surgical method [8-9]. compared the safety and efficacy of laparoscopic surgery, open surgery, endoscopic submucosal dissection (ESD) and endoscopic full thickness resection (eftr) in 114 patients with GIST Gist, endoscopic treatment is an effective, safe and feasible minimally invasive method, which has the advantages of less trauma, faster recovery and shorter postoperative hospital stay than open surgery and laparoscopic surgery [10]. according to the postoperative risk classification and genotyping of gist, imatinib as the first-line representative drug targeting drug is mainly used in patients with moderate and high risk of tumor resection and patients with recurrence and metastasis that can not be completely removed. It is used to inhibit tumor growth, delay disease progression, improve 5-year survival rate and prolong the survival period of patients. gist was divided into low-risk group (very low-risk + low-risk group), medium-risk group and high-risk group according to the consensus on diagnosis and treatment of gastrointestinal stromal tumors in China (2017 Edition). Table 2: gist classification in Chinese expert consensus on diagnosis and treatment of gastrointestinal stromal tumors (2017 Edition) the prognosis of gist is closely related to tumor size and depth of invasion, mitotic index and metastasis. As the growth is vertical rather than invasive, lymph node metastasis is rare in patients [12]. metastasis is related to the location, size and mitotic index of the tumor. in general, gastric GIST with & lt; 5cm mitosis / HPF & lt; 5 / 50hpf is the least malignant, while & gt; 5cm gist with mitosis / HPF & gt; 5 / 50hpf has the highest malignant potential [13-14]. the common metastatic foci include abdominal cavity and liver [15], suggesting that postoperative imaging follow-up and long-term monitoring are needed. in conclusion, ulcer and bleeding may occur in large gist, and occult gastrointestinal bleeding should be considered in clinical practice. References: [1] mirakhor e, Wong MT, Jamil LH. Gastrointinal stromal tumour masquerading as a vertical bleed BMJ case rep 2019; 12:e232169. doi:10.1136/bcr-2019- 232169[2] Miettinen M，Lasota J． Histopathology of gastrointestinal，P'P stromal tumor[J].J Surg Oncol，2011，104（8）：865-873．[3] Kazuya Akahoshi，Masafumi Oya，Tadashi Koga.Clinical usefulness of endoscopic ultrasound-guided fine needle aspiration for gastric subepithelial lesions smaller than 2 cm. Journal of Gastrointestinal & Liver Diseases ，2014,4,405-412. DOI:10.15403/jgld.2014.1121.234.eug [4] Guo Hao, Yang Xingjun. the clinical value of multi-slice spiral CT combined with endoscopic ultrasonography in the diagnosis and prognosis evaluation of gastrointestinal stromal tumors, Chinese Journal of CT and MRI, 2019, 17, 10117-119 [5] Judson I, bulusu R, seddonb, et al. UK clinical practice guidelines for the management of gastrointestinal stromal tumors. Clinical sarcoma res, 2017,7, 6.[6] ＫoDH，Ｒyu MH，Ｋim KM，et al．Asian Consensus Guidelines for the Diagnosis and Management of Gastrointestinal Stromal Tumor Cancer Research & Treatment Official Journal of Korean,2016，48（4）：1155 -1166．[7] Dirnhofer S, Leyvraz S. current standards and progress in understanding and treatment of gist [J], Swiss Med wkly 2009, 139 (7 / 8): 90. [8] Shen Lin, Cao Hui, Qin Shuxuan, et al. Chinese consensus on diagnosis and treatment of gastrointestinal stromal tumors (2017). Electronic Journal of comprehensive cancer therapy, 2018.4 (1): 31-43. [9] Feng Xingyu, Li Renjie, Zhang Peng, et al. Analysis of the current status of surgical treatment of gastrointestinal stromal tumors derived from stomach based on Chinese multicenter data [} 7. Chinese Journal of gastrointestinal surgery, 2016.19 (11): 1258-1264. [10] Li Suqin, Li Xia, Zhu Xiaoyun, Yu Honggang. clinical comparative study of four surgical methods in the treatment of gastrointestinal stromal tumor. 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