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

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

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: 7,010-12.1/35.4-259k T.Bil/AST/ALT/ALP 0.8/47/81/564 AFP 3.14

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

Single Balloon Enteroscopy (oral route)

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 (+)

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

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

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

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 (-/-)

Initial Laboratory Data Physical examination V/S 103/60-80-20-37.2 Anicteric sclerae, Pale conjunctivae Abdomen Soft and flat, Normoactive bowel sound DT/RT(-/-) , No palpable mass Initial Laboratory Data CBC 3,630-7.2/21.2-237K 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

CT Angio + GI Bleeding 3D Arterial Phase Portal Phase

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

Oblique-viewing Echoendoscope

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)

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

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®)

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