Unusual case report of bifocal gastrointestinal stromal tumor in the first jejunal loop uncovered by severe hemorrhage.

INTRODUCTION AND IMPORTANCE: Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors, constituting 1 % of gastrointestinal tumors. Jejunal GISTs are even rarer. This article describes a unique bifocal jejunal GIST case, revealed by an exceptionally rare instance of massive hemorrhage. CASE PRESENTATION: We present a 60-year-old female admitted for two days of melena. Despite being hemodynamically stable, severe anemia was noted. Initial endoscopy was normal, but further imaging and jejunoscopy revealed two jejunal GISTs. Surgical resection confirmed the diagnosis. Postoperative recovery was uneventful, with no bleeding recurrence after one year. CLINICAL DISCUSSION: Gastrointestinal stromal tumors (GISTs) are rare but the most common mesenchymal neoplasms in the gastrointestinal tract, originating from interstitial cells of Cajal. Jejunal GISTs are particularly rare but can cause severe gastrointestinal bleeding, even if small. Diagnosis is challenging and often confirmed by angio-CT. Upper and lower endoscopies are initial steps in evaluating gastrointestinal bleeding, but jejunal GISTs may not be visible due to limited access. In such cases, jejunoscopy and video capsule endoscopy can be particularly valuable for direct visualization and assessment of the jejunum, as demonstrated in our patient, where jejunoscopy enabled precise diagnosis. Complete surgical resection is the recommended treatment, with CD-117 positivity confirming the diagnosis. CONCLUSION: This case highlights the rare presentation of bifocal jejunal GISTs with severe hemorrhage and emphasizes the need for prompt surgical intervention and awareness of atypical cases.

A rare case report: Spontaneous rectus sheath and iliopsoas hematomas: Clinical presentation, management, and implications.

INTRODUCTION AND IMPORTANCE: Frequently misdiagnosed, the clinical condition of soft tissue hematoma typically emerges following blunt abdominal trauma and/or anticoagulant medication usage, with spontaneous occurrences being infrequent. In this case report, we present a spontaneous rectus sheath and iliopsoas hematomas without obvious classical risk factors. The purpose of presenting this case is to bring attention to this unusual clinical condition and emphasize the role of thorough history and physical examination in determining the suitable course of treatment. CASE REPORT: A 50-year-old woman with no medical history presented at the emergency room due to sudden asthenia and abdominal pain. Physical examination revealed a painful 20 cm hypogastric mass and left lumbar swelling causing leg bending. Lab tests indicated anemia and normal coagulation. CT scans showed significant hematomas in the left rectus and psoas muscles. Intensive monitoring and supportive measures stabilized her condition without resorting to surgery. CLINICAL DISCUSSION: Soft tissue hematomas, notably in the rectus sheath or iliopsoas muscle, are rare but potentially severe conditions. Their pathophysiology is not fully understood, and risk factors include age, anticoagulant use, and comorbidities. Diagnosis involves abdominal examination, anemia, and CT findings. Management varies based on symptom severity and blood loss, ranging from conservative approaches to surgery or embolization. CONCLUSION: Swift identification and effective handling of soft tissue hematomas hold utmost importance. The thorough history-taking and comprehensive physical examination play pivotal roles within this protocol. While supportive care constitutes the primary mode of management, instances arise where surgical intervention or vascular embolization becomes imperative for hematomas unresponsive to treatment and presenting hemodynamic instability.

Revelation of Rapunzel syndrome: A rare case report of gastric trichobezoar-induced acute purulent peritonitis.

INTRODUCTION AND IMPORTANCE: The Rapunzel syndrome embodies an uncommon variation of trichobezoar, predominantly observed among individuals with a history of psychiatric conditions, trichotillomania, and trichophagia. This combination of factors predisposes to the eventual formation of gastric bezoars. Trichobezoars, infrequent gastric masses composed of hair, can lead to complications if left untreated. CASE REPORT: A 19-year-old female hairdresser with a history of trichophagia sought medical attention due to abdominal pain and episodes of vomiting. With an elevated body temperature and abdominal rigidity, imaging revealed the presence of a trichobezoar, accompanied by pneumoperitoneum and intraperitoneal effusion. Urgent surgical intervention confirmed the diagnosis of generalized purulent acute peritonitis, triggered by a gastric perforation caused by a 20 cm trichobezoar with an extension into the duodenum, which defines the Rapunzel syndrome. Gastrotomy was performed to remove the trichobezoar, followed by thorough peritoneal lavage. CLINICAL DISCUSSION: Trichobezoar is a rare condition that involves the abnormal accumulation of solid substances, particularly hair, within the stomach. Known as "Rapunzel syndrome," it can extend into the duodenum or jejunum. Commonly associated with emotional disorders, trichobezoar can lead to symptoms like epigastric discomfort, vomiting, and weight loss. Diagnosis is through endoscopy, and treatments include fluid intake, endoscopic extraction, chemical dissolution, and surgical removal. Surgical intervention is often preferred, with laparoscopic approaches considered. Psychiatric management is often required for patients. CONCLUSION: This case underscores the uncommon Rapunzel syndrome presentation, emphasizing timely surgical measures and multidisciplinary care for trichobezoars causing acute peritonitis.