El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy
Gastrointestinal Stromal Tumor (GIST)  This 64 year-old, male due to an abdominal pain a cat scan was performed finding a large mass in the stomach an endoscopy was performed a submucosal mass was detected.

Video Endoscopic Sequence 1 of 13.

Gastrointestinal Stromal Tumor (GIST)

 This 64 year-old, male due to an abdominal pain a cat scan
 was performed finding a large mass in the stomach an
 endoscopy was performed; a submucosal mass was
 detected.

 A case of Jejunal GIST is displayed in the Jejunum-Ileum
 chapter.
Also a case of Rectal GIST is in the
 Miscellaneous chapter

 For more endoscopic details download the video clips by
 clicking on the endoscopic images, wait to be downloaded
 complete then press Alt and Enter; thus you can observe
 the video in full screen.

 All endoscopic images shown in this Atlas contain
 video clips
       

Gastroscopy showed a large sub mucosal tumor, Gastrointestinal stromal tumour (GIST) is a new term emerging from reclassification of leiomyomas and leiomyosarcomas of the gastrointestinal tract. Histopathological refinement, molecular genetics and immunophenotypic characterization has resulted in better understanding and sub classification of this disease entity.

Video Endoscopic Sequence 2 of 13.

Gastroscopy showed a large sub mucosal tumor

 Gastrointestinal stromal tumour (GIST) is a new term
 emerging from reclassification of leiomyomas and
 leiomyosarcomas of the gastrointestinal tract.
 Histopathological refinement, molecular genetics and
 immunophenotypic characterization has resulted in better
 understanding and sub classification of this disease entity.

Gastrointestinal stromal tumors formely classified as leiomyomas or leiomyosarcomas are mesenchymal tumors of the gastrointestinal tract that differ from true Leiomyomas and Leiomyosarcomas. Classification of mesenchymal tumors of the gastrointestinal tract has been the subject of controversies for many years and several histological classification system has been proposed. GIST are now defined as spindle cell, epitheloid or occasionally pleomorphic mesenchymal tumors of the gastrointestinal tract without smooth muscle cell or schwann cell differentiation  The term GIST is also limited to tumors originating from pacemaker cell of Cajal located between myenteric plexus cells and smooth muscle cells of the GIT. The immuno-histo chemical marker 'C-Kit' (CD-117) identifies these cell and seems to be the most specific diagnostic marker currently available.

Video Endoscopic Sequence 3 of 13.

 Gastrointestinal stromal tumors formely classified as
 leiomyomas or leiomyosarcomas are mesenchymal tumors
 of the gastrointestinal tract that differ from true
 Leiomyomas and Leiomyosarcomas. Classification of
 mesenchymal tumors of the gastrointestinal tract has been
 the ၳubject of controversies for many years and several
 histological classification system has been proposed. GIST
 are now defined as spindle cell, epitheloid or occasionally
 pleomorphic mesenchymal tumors of the gastrointestinal
 tract without smooth muscle cell or schwann cell
 differentiation The term GIST is also limited to tumors
 originating from pacemaker cell of Cajal located between
 myenteric plexus cells and smooth muscle cells of the GIT.
 The immuno-histo chemical marker 'C-Kit' (CD-117)
 identifies these cell and seems to be the most specific
 diagnostic marker currently available.

 

Gastrointestinal Stromal Tumors (GISTs). Gastrointestinal Stromal Tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract.

Video Endoscopic Sequence 4 of 13.

 Endoscopic Image of Gastrointestinal Stromal Tumors (GISTs)

 Gastrointestinal Stromal Tumors (GISTs) are the most
 common mesenchymal tumors of the gastrointestinal tract.

 

Endoscopic View of Gastrointestinal Stromal Tumor (GIST). A palpable abdominal mass is the most frequent presentation but 50% of GISTs are silent until they reach a large size, then causing acute massive hemorrhage into the intestinal tract or peritoneal cavity from tumor rupture. This is the second most common presentation. Other presenting symptoms include nausea, dyspepsia and intestinal obstruction as a result of extrinsic compression.

Video Endoscopic Sequence 5 of 13.

 Endoscopic View of Gastrointestinal Stromal Tumor (GIST)

 A palpable abdominal mass is the most frequent
 presentation but 50% of GISTs are silent until they reach
 a large size, then causing acute massive hemorrhage into
 the intestinal tract or peritoneal cavity from tumor rupture.
 This is the second most common presentation. Other
 presenting symptoms include nausea, dyspepsia and
 intestinal obstruction as a result of extrinsic compression.

Resection remains the standard treatment for non-metastatic GISTs. These tumors may have a pseudocapsule and should be removed. Complete resection of GIST is not curative as recurrence is quite common. In patients with local disease, the recurrence rate is 35%. A major diagnostic criterion of GISTs is expression of CD117 and additional criteria include CD34, SMA, S100 and desmin.

Video Endoscopic Sequence 6 of 13.

 Resection remains the standard treatment for
 non-metastatic GISTs. These tumors may have a
 pseudocapsule and should be removed. Complete resection
 of GIST is not curative as
recurrence is quite common. In
 patients with local disease, the
recurrence rate is 35%. A
 major diagnostic criterion of GISTs is expression of
 CD117 and additional criteria include CD34, SMA, S100
 and desmin.

 

GIST:Differential Diagnosis:

Video Endoscopic Sequence 7 of 13.

 GIST:Differential Diagnosis:

    • Gastrointestinal carcinoid
    • Adenocarcinoma
    • Gastric carcinoma
    • Liposarcoma
  • Others to be Considered: Angiosarcoma Inflammatory
     fibroid polyp,
    Inflammatory myofibroblastic tumor
     (pseudotumor, fibrosarcoma) i
    ntra-abdominal fibromatosis
     
    Kaposi sarcoma,Lipoma, Lymphoma,
     abdominal
    Melanoma, metastatic Schwannoma, GI.
Endoscopic ultrasound:

Video Endoscopic Sequence 8 of 13.

Endoscopic ultrasound:

    • hypoechoic masses that are contiguous with the fourth hypoechoic layer of the GI wall, which corresponds to the muscularis propria
    • Characteristics associated with malignancy include tumor size greater than 4 cm, an irregular extraluminal border, echogenic foci, and cystic spaces.
In this sequence of images of the computer tomography shows a large mass inside and outside of the stomach, a left renal cyst is also seen.

Video Endoscopic Sequence 9 of 13.

 In this sequence of images of the computer tomography
 shows a large mass inside and outside of the stomach, a
 left renal cyst is also seen.

CT is ideal in defining the endoluminal and exophytic extent of tumor.

Video Endoscopic Sequence 10 of 13.

CT is ideal in defining the endoluminal and exophytic extent of tumor.

  • Smaller GISTs appear as smooth, sharply defined intramural masses with homogenous attenuation.
  • Larger GISTs with necrosis appear as heterogeneous masses with enhancing borders of variable thickness and irregular central areas of fluid, air, or oral contrast attenuation that reflect necrosis
  • Occasionally, dense focal calcifications
  • Overlying mucosal ulcerations and extension into nearby structures may be present. 
GIST: benign vrs malignant.

Video Endoscopic Sequence 11 of 13.

GIST: benign vrs malignant

  • Unfortunately, no standard exists for their classification.
    • Many criteria such as number of mitotic figures, size, presence of necrosis and hemorrhage among others.
    • Size is the most important and most reliable
      • Tumor <5 cm is described as having low malignancy potential
      • Tumor >5 cm is described as being of high malignancy potential.
GastricGistzxc12

Video Endoscopic Sequence 12 of 13.

 Upper GI bleeding is the most common clinical
 manifestation of gastrointestinal stromal tumors (GISTs),
 manifesting as hematemesis or melena in 40-65% of
 patients. Bleeding occurs because of an ulcer forming in
 the gastric mucosa overlying the tumor.

 

Imaging studies, especially CT, play an important role not only in the detection and the localization but also in the evaluation of the extension and follow-up of theses tumors. Small GISTs are intraluminal, localized, and well-defined, whereas extensive GISTs are large and hypervascular and may contain cystic and necrotic tumor components combined with an intra-/extraluminal tumor growth. CT diagnosis of malignant GISTs can be suggested in the presence of a large, complex, gastro-intestinal mass, without significant lymphadenopathy. It is difficult to differentiate, using only CT imaging, the GIST from other soft-tissue tumors. In all cases, histological diagnosis is essential and compulsory.

Video Endoscopic Sequence 13 of 13.

 Imaging studies, especially CT, play an important role not
 only in the detection and the localization but also in the
 evaluation of the extension and follow-up of theses tumors.
 Small GISTs are intraluminal, localized, and well-defined,
 whereas extensive GISTs are large and hypervascular and
 may contain cystic and necrotic tumor components
 combined with an intra-/extraluminal tumor growth. CT
 diagnosis of malignant GISTs can be suggested in the
 presence of a large, complex, gastro-intestinal mass,
 without significant lymphadenopathy. It is difficult to
 differentiate, using only CT imaging, the GIST from other
 soft-tissue tumors. In all cases, histological diagnosis is
 essential and compulsory.

Enormous gastric leiomyoma with a central umbilicated ulceration. A 34 year-old male with hepatic cirrhosis and esophageal varices presented a submucosal tumor with central umbilicated ulcer. He was asymptomatic at the time of dignosis. The central location of this ulcer is characteristic for an intramural neoplasm such a leiomyoma.

Video Endoscopic Sequence 1 of 6.

 Enormous Gastric Gastrointestinal Stromal Tumor (GIST)
 with a central umbilicated ulceration.

 A 34 year-old male with hepatic cirrhosis and esophageal
 varices, presented a submucosal tumor with central
 umbilicated ulcer. He was asymptomatic at the time of
 diagnosis.
 
The central location of this ulcer is characteristic for an
 intramural neoplasm such a GIST


                                          Medline.
 
 For more endoscopic details download the video clips by
 clicking on the endoscopic image.
 
All endoscopic images shown in this Atlas contain a video
 clip.
We recommend seeing the video clips in full screen
 mode.

 Another view of the tumor described above. Grossly, leiomyomas of the stomach most frequently develop in the lower half of the stomach but may also be seen at the fundus. They are usually smaller than 3 cm but occasionally may be large at the time of diagnosis. Ulceration of the mucosa overlying the tumor is reported in 50 - 70% of tumors larger than 2 cm in diameter. Most gastric leiomyomas present as endogastric submucosal lesions and may be pedunculated but some, originating from the serosa, develop mainly as exogastric masses.

Video Endoscopic Sequence 2 of 6.

Another view of the tumor described above.

 Grossly, GIST of the stomach most frequently
 develop in the lower half of the stomach but may also be
 seen at the fundus. They are usually smaller than 3 cm but
 occasionally may be large at the time of diagnosis.
 Ulceration of the mucosa overlying the tumor is reported in
 50 – 70% of tumors larger than 2 cm in diameter. Most
 gastric leiomyomas present as endogastric submucosal
 lesions and may be pedunculated but some, originating from
 the serosa, develop mainly as exogastric masses.
    

Lateral view of this submucosal tumor.  The classic or usual GI tract leiomyoma has a similar morphologic appearance to leiomyomas in other organs. In the gut, they are usually small, and well circumscribed. The tumors typically arise from the muscularis propria; growth may be intraluminal, extraluminal, or a combination with a dumb-bell shape. Leiomyomas can range in size from less than 0.5 cm (microleiomyomas) to as large as 30 cm.

 Video Endoscopic Sequence 3 of 6.

Lateral view of this submucosal tumor.

 The classic or usual GI tract GIST has a similar
 morphologic appearance to leiomyomas in other organs. In
 the gut, they are usually small, and well circumscribed. The
 tumors typically arise from the muscularis propria; growth
 may be intraluminal, extraluminal, or a combination with a
 dumb-bell shape. GIST can range in size from less
 than 0.5 cm (microgist
) to as large as 30 cm.

                                          Medline.

Upper endoscopy image showing Gastrointestinal Stromal. Most leiomyomas of stomach are asymptomatic but ulceration may cause pain and signs of gastrointestinal  bleeding.  Microscopically, leiomyomas are formed of fasicles of benign-appearing spindle cells without nuclear atypia; mitoses are sparse or absent, and necrosis virtually never occurs.  The nucleus is centrally located and oval but may be displaced to one side by distinct vacuoles suggesting signet-ring cells. These vacuoles do not contain fat or mucosubstances, which differentiates them from liposarcomas and carcinomas.

Video Endoscopic Sequence 4 of 6.

 Upper endoscopy image showing Gastrointestinal Stromal
 Tumor (GIST)

 Most GIST of stomach are asymptomatic but
 ulceration may cause pain and signs of gastrointestinal
 bleeding.

 Microscopically, GIST are formed of fasicles of
 benign-appearing spindle cells without nuclear atypia;
 mitoses are sparse or absent, and necrosis virtually never
 occurs. The nucleus is centrally located and oval but may
 be displaced to one side by distinct vacuoles suggesting
 signet-ring cells. These vacuoles do not contain fat or
 mucosubstances, which differentiates them from
 liposarcomas and carcinomas.
                                                                  Medline.

Magnifycation of the tip of the leiomyoma.  A Magnifying endoscope was used.

Video Endoscopic Sequence 5 of 6.

 Magnifycation of the tip of the GIST. A Magnifying
 endoscope was used.

 

 

                                         Medline.

Some biopsies were taken and proved to be a leiomyoma.

Video Endoscopic Sequence 6 of 6.

Some biopsies were taken and proved to be a GIST

 

GistMemo1

Video Endoscopic Sequence 1 of 3.

Gastric Gastrointestinal Stromal Tumor (GIST)

This 59 year-old female presented with abdominal pain and melena.

Gastrointestinal stromal tumors (GISTs) are mesenchymal neoplasms of the gastrointestinal (GI) tract and are thought to develop from the interstitial cells of Cajal, innervated cells associated with the Auerbach plexus. GISTs are typically defined by the expression of c-KIT (CD117) in the tumor cells, as these activating KIT mutations are seen in 85-95% of GISTs. About 3-5% of the remainder of KIT -negative GISTs contain PDGFR alpha mutations

 

 

GistMemo2

Video Endoscopic Sequence 2 of 3.

This image and the video clips shows the diameter of the tumor.

 The discovery in 2000 of the efficacy of imatinib, an
 inhibitor of the BCR-ABL oncoprotein used in the
 treatment of chronic myeloid leukemia (CML), in treating
 metastatic gastrointestinal stromal tumor has
 revolutionized the care of patients with GISTs. Prior to the
 advent of immunohistochemical methods enabling the
 specific identification of c-KIT positive tumors, these
 tumors were inaccurately classified as gastric or intestinal
 smooth muscle tumors (leiomyomas or leiomyosarcomas).

GistMemo3

Video Endoscopic Sequence 3 of 3.

 Note the submucosal tumor mass with the classic features of central umbilication and ulceration.

 GISTs are typically diagnosed as solitary lesions, although
 in rare cases, multiple lesions can be found. These tumors
 can grow intraluminally or extraluminally toward adjacent
 structures. When the growth pattern is extraluminal,
 patients can harbor the disease symptom free for an
 extended period and present with very large exogastric
 masses.

 Distant metastases tend to appear late in the course of the
 disease in most cases. In contrast to other soft tissue
 tumors, the common metastatic sites of GISTs are the liver
 and peritoneum. Lymph node involvement is rare,
 occurring in only 0-8% of cases.

Multiple Gastric Leiomiomas. A 20 year-old female that have been under anemia screening. Endoscopically multiples gastric leiomiomas in the posterior wall of the stomach from the antrum to the fundus were found. The patient underwent a subtotal gastrectomy and local resection of leiomiomas of the fundus was performed. Medical literature describes five similar cases reported previously.

Multiple Gastric Gastrointestinal Stromal Tumor (GIST)

 A 20 year-old female that have been under anemia
 screening.
 Endoscopically multiples gastric leiomiomas in the
 posterior wall of the stomach from the antrum to the fundus
 were found.
 The patient underwent a subtotal gastrectomy and local
 resection of leiomiomas of the fundus was performed.
 Medical literature describes five similar cases reported
 previously. 

Gastrointestinal Stromal Tumor (GIST). This 42 year-old lady who underwent a routine endoscopy, a submucosa mass was found, a laparoscopic resection is performed with the attends of GI endoscopy.

Video Endoscopic Sequence 1 of 65.

Gastrointestinal Stromal Tumor (GIST).

 This 42 year-old lady who underwent a routine endoscopy,
 a submucosa mass was found, a laparoscopic resection is
 performed with the attends of GI endoscopy.

 

Retroflexed image.

Video Endoscopic Sequence 2 of 65.

Retroflexed image.

 Gastrointestinal stromal tumors (GISTs) are rare.
 Nevertheless, some may present with a life-threatening
 hemorrhage or intestinal obstruction.

 

Due to this ulcer some biopsies were taken.

Video Endoscopic Sequence 3 of 65.

Due to this ulcer some biopsies were taken.

We tried to banding this submucous mass but due to the size a little greater, we did not continue treating.

Video Endoscopic Sequence 4 of 65.

 We tried to banding this submucous mass, but due to the size a little greater, we did not continue treating.

GistGastric5

Video Endoscopic Sequence 5 of 65.

Biopsies of great size were taken.

 

Adrenalin dilution of 1/10000 and 50% Dextrose.

Video Endoscopic Sequence 6 of 65.

Adrenalin dilution of 1/10000 and 50% Dextrose.

 

GistGastric7

Video Endoscopic Sequence 7 of 65.

 

GistGastric8

Video Endoscopic Sequence 8 of 65.

 

GistGastric9

Video Endoscopic Sequence 9 of 65.

 

GistGastric10

Video Endoscopic Sequence 10 of 65.

 

GistGastric11

Video Endoscopic Sequence 11 of 65.

Patient underwent an assisted laparoscopic resection.

Patient underwent a laparoscopic resection.

 This video sequence shows the laparoscopic steps of this
 surgery.

 The increased use of laparoscopy in the management of
 gastrointestinal problems continues to expand. Procedures
 such as jejunostomies, diagnosis of intestinal obstruction or
 ischemia, resection of the small bowel, and lysis of
 adhesions can be managed with this technique.

The surgeon is performing some marks were the exact site of the submucosa mass will be resected.

Video Endoscopic Sequence 12 of 65.

The surgeon is performing some marks were the exact site of the submucosa mass will be resected. 

This video clip shows the light of the laparoscope that transluminate through the gastric mucosa.

Video Endoscopic Sequence 13 of 65.

This video clip shows the light of the laparoscope that transluminate through the gastric mucosa.

Video Endoscopic Sequence 14 of 65.

 Laparoscopic resection was planned after the abdominal
 distension subsided. Pneumoperitoneum was established
 with a Veress needle. A 5mm trocar was introduced in the
 umbilical incision; a 5mm (0) telescope was introduced and
 the other two 5mm ports were inserted under vision – one
 in the right midclavicular line and the other in the left
 midclavicular line, below the level of the umbilicus.

GistEndoscopicPeritineoscopy2

Video Endoscopic Sequence 15 of 65.

 

For many GI malignancies, laparoscopic surgery is safe and technically feasible, albeit with a somewhat longer learning curve compared to open surgery. Advanced procedures are technically demanding and require more operative time.

Video Endoscopic Sequence 16 of 65.

 For many GI malignancies, laparoscopic surgery is safe
 and technically feasible, albeit with a somewhat longer
 learning curve compared to open surgery. Advanced
 procedures are technically demanding and require more
 operative time.

Video Endoscopic Sequence 17 of 65.

 Surgery remains the standard for nonmetastatic
 gastrointestinal stromal tumors (GISTs). Laparoscopic
 surgery should be considered for these tumors as their
 biologic behavior lends them to curative resection without
 requiring large margins or extensive lymphadenectomies.

Video Endoscopic Sequence 18 of 65.

 

Video Endoscopic Sequence 19 of 65.

 

Video Endoscopic Sequence 20 of 65.

 

Video Endoscopic Sequence 21 of 65.

 

Video Endoscopic Sequence 22 of 65.

 

Video Endoscopic Sequence 23 of 65.

 

GistEndoscopicPeritineoscopy6

Video Endoscopic Sequence 24 of 65.

GistGastric20

Video Endoscopic Sequence 25 of 64.

GistGastric21

Video Endoscopic Sequence 26 of 64.

 

Video Endoscopic Sequence 27 of 64.

The GI gastroscope is inside of the abdominal cavity.

Video Endoscopic Sequence 28 of 64.

 

Video Endoscopic Sequence 29 of 64.

The gastroscope is inspecting the gallbladder.

Video Endoscopic Sequence 30 of 64.

Video Endoscopic Sequence 31 of 64.

 

Video Endoscopic Sequence 32 of 64.

 

GistEndoscopicPeritineoscopy11

Video Endoscopic Sequence 33 of 64.

 

GistGastric26

Video Endoscopic Sequence 34 of 64.

 

Video Endoscopic Sequence 35 of 64.

 

Video Endoscopic Sequence 36 of 64.

 

GistGastric29

Video Endoscopic Sequence 37 of 64.

GistEndoscopicPeritineoscopy10

Video Endoscopic Sequence 38 of 64.

 

Video Endoscopic Sequence 39 of 64.

 

GistEndoscopicPeritineoscopy12

Video Endoscopic Sequence 40 of 64.

 

Video Endoscopic Sequence 41 of 64.

Intraoperative video clip showing the linear stampler
applied to the stomach.

 Stapled laparoscopic resection is a safe and effective
 treatment option for nonmetastatic primary jejunal GIST.

 

Video Endoscopic Sequence 42 of 64.

 

Video Endoscopic Sequence 43 of 64.

 

Video Endoscopic Sequence 44 of 64.

 

Video Endoscopic Sequence 45 of 64.

 

Video Endoscopic Sequence 46 of 64.

 

Video Endoscopic Sequence 47 of 64.

 

Video Endoscopic Sequence 48 of 64.

 

Video Endoscopic Sequence 49 of 64.

Video Endoscopic Sequence 50 of 64.

 

GistGastric40

Video Endoscopic Sequence 51 of 64.

 

GistGastric41

Video Endoscopic Sequence 52 of 65.

 

GistGastric42

Video Endoscopic Sequence 53 of 65.

GistGastric43

Video Endoscopic Sequence 54 of 65.

 

GistGastric44

Video Endoscopic Sequence 55 of 65.

 

GistGastric45

Video Endoscopic Sequence 56 of 65.

 

GistGastric46

Video Endoscopic Sequence 57 of 65.

 

Video Endoscopic Sequence 58 of 65.

 

Low power of the stromal tumor showing the muscularis propria of stomach

Video Endoscopic Sequence 59 of 65.

 Low power: Stromal tumor showing the muscularis
 propria of stomach.

GistGastric49

Video Endoscopic Sequence 60 of 65.

 

GistGastric50

Video Endoscopic Sequence 61 of 65.

 

Video Endoscopic Sequence 62 of 65.

 

GistGastric52

Video Endoscopic Sequence 63 of 65.

 

GistGastric53

Video Endoscopic Sequence 64 of 65.

 

GistGastric54

Video Endoscopic Sequence 65 of 65.