Giant small-bowel GI stromal tumor: aspirin provocation to endoscopically unmask site of obscure overt GI bleeding

Letters to the Editor

incision, whereas precut papillotomy is a free-hand technique, and the incision may not be well controlled. However, in a case like that reported by Garcia-Cano, the guidewire may be a good aid for directing the precut incision. Sri Prakash Misra, MD, DM, FRCP, FACG Manisha Dwivedi, MD, DM, FACG Department of Gastroenterology Moti Lal Nehru Medical College University of Allahabad Allahabad, India Figure 1. An antegrade enteroscopy revealed a raised dark red spot (arrow) in the jejunum.

REFERENCE 1. Misra SP, Dwivedi M. Intramural incision technique: a useful and safe procedure for obtaining ductal access during ERCP. Gastrointest Endosc 2008;67:629-33. doi:10.1016/j.gie.2008.03.1119

Giant small-bowel GI stromal tumor: aspirin provocation to endoscopically unmask site of obscure overt GI bleeding A 43-year-old man electively presented with a several-year history of intermittent severe GI bleeding. Aspirin consistently provoked the bleeding. Evaluation with upper endoscopy, enteroscopy, capsule endoscopy, and colonoscopy, as well as small-bowel series, Meckel’s scan, and angiography was nondiagnostic. We admitted the patient and prescribed aspirin followed by capsule endoscopy. Active bleeding was seen in the jejunum. An antegrade double-balloon enteroscopy revealed a dark red spot in the jejunum (Fig. 1). The enteroscope, however, could not be advanced to the site, and fluoroscopically, it was displaced to the left. Two mL of India ink was injected submucosally a few cm proximal to the dark spot. We then proceeded with intraoperative enteroscopy. At laparoscopy, a 20-cm extraluminal encapsulated mass with mucosal ulceration at its point of attachment to the jejunum was found (Fig. 2). The tattoo was seen near the bleeding site (Fig. 2). The use of provocation in highly selected patients may assist in the endoscopic localization of recurrent obscure GI bleeding.1 Though not part of the diagnostic algorithm,2 a CTor magnetic resonance of the abdomen may have expedited the diagnosis of jejunal GI stromal tumor in this patient.3

Figure 2. At laparoscopy, a 20-cm extraluminal encapsulated mass with mucosal ulceration (arrow) at its point of attachment to the jejunum was found. The tattoo was seen near the bleeding site (double arrow).

Margaret Allen, LVN Kenneth Binmoeller, MD Roy Soetikno, MD, MS Interventional Endoscopy Service California Pacific Medical Center San Francisco, California, USA REFERENCES 1. Berkelhammer C, Radvany A, Lin A, et al. Heparin provocation for endoscopic localization of recurrent obscure GI hemorrhage. Gastrointest Endosc 200;52:555–6. 2. Gralnek IM. Obscure-overt gastrointestinal bleeding. Gastroenterology 2005;128:1424-30. 3. Sass DA, Chopra KB, Finkelstein SD, et al. Jejunal gastrointestinal stromal tumor: a cause of obscure gastrointestinal bleeding. Arch Pathol Lab Med 2004;128:214-7. doi:10.1016/j.gie.2008.02.090

The nonlifting sign and forceps biopsy Tonya Kaltenbach, MD, MS Patricia Cabral, MD Interventional Endoscopy Service Laurence Yee, MD Department of Surgery 1026 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 5 : 2008

To the Editor: In a recent article, Han et al,1 reported on the nonlifting sign (NLS), a sign that was initially reported in 1994.2 www.giejournal.org