37 years old lady with abdominal lump on left upper abdomen. Based on history and examination,D/D- GIST,Mesenteric Cyst, Lymphoma.

1. Clinical
Case Presentation
Dr. Noushin Nowar
FCPS Trainee, Surgery Unit-VI
Dhaka Medical College Hospital, Dhaka

2. 37 years old lady with abdominal lump

3. Name: Mrs. Mohsena Begum
Age: 37 years
Sex: Female
Address: Brahmanbaria
Marital status: Married
Religion : Islam
Occupation: Housewife
Date of admission: 04.03.2021 at 10.00 AM
Date of examination: 04.03.2021 at 11.00 AM
PATIENT PROFILE

4.  Lump in left upper abdomen for 6 months.
 Pain in the left upper abdomen for 3 months.
CHIEF COMPLAINTS

5. History of Presenting Illness
According to the statement of the patient, she was reasonably well about 6
months back. Then she noticed a lump in the left upper abdomen, which was
gradually increasing in size. Initially it was painless but for the last 3 months
she experienced pain in the left upper abdomen which was constant and dull
aching in nature with some dragging discomfort. Pain had no relation with
meal. Pain had no aggravating and relieving factors and it was non radiating.
Continued...

6. She had no history of vomiting, abdominal distension, alteration of bowel
habit, fever, passing of black or altered color stool and blood with urine. She
had no significant travelling and blood transfusion history.
She didn’t gave any history of loss of appetite, weight loss, bone pain, chest
pain, jaundice and coughing out of blood. Her bladder habit was normal.
She was normotensive, non-diabetic and non-asthmatic.
History of Presenting Illness

7. She had abdominal hysterectomy 5 years back.
History of Past Illness

8.  She lives with two children and her husband.
 None of her relatives have any history of similar illness .
Family History
Personal History
 Non-Smoker, Non-Alcoholic
 Chews betel nut
 Takes traditional bengali diet

9. Socio-economic Condition
Allergic History
 No known allergy to any foods or drugs.
 Low socio-economic background
 Lives in a tin-shed house
 Uses sanitary facilities outside of home
 Drinks tubewell water.

10.  Amenorrheic for 5 years since hysterectomy
Immunization History
Menstrual history
She was immunized as per EPI schedule.

11. General Examination
Appearance : Ill-looking
Body Built : Average
Nutritional Status : Average
Co-Operation : Co-operative
Decubitus : On choice
Anemia : Present (+)
Jaundice : Absent
Cyanosis : Absent
Oedema : Absent
Dehydration : Absent
Continued...

12. Pigmentation : Absent
Clubbing : Absent
Koilonychia : Absent
Leukonychia : Absent
Neck veins : Not engorged
Lymph nodes : Accessible LN were not enlarged
Blood pressure : 110/80 mmHg
Pulse : 80 bpm
Temperature : 98° F
Respiratory rate : 18 breaths/min
General Examination

13. On Inspection-
Shape of the abdomen- Normal
Flanks- Not full
Umbilicus inverted and centrally placed
No visible lump
No visible pulsation or peristalsis are seen
Hair distribution- Normal
Skin condition- Normal, there was a healed pfannenstiel incisional
scar mark in lower abdomen
Abdominal Examination
Continued...

14. On Palpation-
Superficial palpation-
There was a lump in the left hypochondriac and left lumbar
region.
No muscle guard or rigidity observed.
Continued...
Abdominal Examination

15. Deep palpation-
There was a lump occupying the left hypochondriac and left lumbar
region measuring approximately 7×10 cm, firm in consistency,
irregular surface and ill-defined margin. It was slightly mobile in both
upwards and side to side direction, didn’t move with respiration,
could be separately palpated from costal margin. It was mildly tender
and non pulsatile.
Continued...
Abdominal Examination

16. Deep palpation-
Lump becomes less prominent in head rising position, but more
prominent in knee elbow position.
Insinuation - Possible
Liver, Gall Bladder, Spleen– Not Palpable
Kidneys- Not bimanually palpable neither ballotable.
Continued...
Abdominal Examination

17. Percussion-
Tympanic all over the abdomen except over the lump which was dull.
Upper border of liver dullness- in 5th ICS on right midclavicular line.
Shifting dullness - Absent
Auscultation-
Bowel sound- Present, Normal.
No bruit over the lump.
Continued...
Abdominal Examination

18. Per Rectal Examination :
Showed no abnormality.
Abdominal Examination

19. Other systemic examinations revealed no abnormality.
Systemic Examination

20. Mrs. Mohsena, 37 years old muslim, married housewife hailing from Brahmanbaria
presented with the complaints of lump in the left hypochondriac and left lumbar region for
6 months which was gradually increasing in size. For the last 3 months lump was associated
with constant, dull aching pain without any relation with meal, no history of radiation ,
aggravating and relieving factor. She gave no history of vomiting, abdominal distension,
alteration of bowel habit, hematemesis, melena, fever.
Salient Features Continued...

21. On general examination, She was mildly anemic but non-icteric. Vital parameters were
within normal limit. Accessible lymph nodes were not enlarged. On abdominal examination-
There was an intra-abdominal lump in the left hypochondriac and left lumbar region
measuring approximately 7×10cm, firm in consistency, irregular surface and ill-defined
margin. It was slightly mobile in both upwards and side to side direction, didn’t move with
respiration, can be separately palpated from costal margin. It was mildly tender and non
pulsatile. Liver, spleen & kidneys were not palpable, shifting dullness was absent. Per rectal
examination revealed no abnormality.
Salient Features

22. Provisional Diagnosis

23. Intra-abdominal Lump-
Gastrointestinal stromal tumour
Provisional Diagnosis

24.  Mesenteric Cyst
 Lymphoma
Differential Diagnosis

25. Investigations

26. USG of Whole Abdomen

27.  A poorly heterogenous complex mass
with irregular margin is seen in left
hypochondriac region (64mm × 46mm).
 Origin couldn’t be determined.
 Mass separated from left lobe of liver,
left kidney, pancreas and spleen.
USG of Whole Abdomen

28. CT Scan of Whole Abdomen

29. CT Scan of Whole Abdomen

30. Comment- Small Bowel GIST.
Heterogenous enhancing mass lesion arising from
small bowel resulting luminal narrowing.
CT Scan of Whole Abdomen

31. Pre-operative
Hb % 10.7 g/dL
Total WBC Count
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
10.14×10^3/𝑚𝑚3
58.4×10^3/ul
37.3×10^3/ul
2.7×10^3/ul
1.5×10^3/ul
0.1×10^3/ul
Total Platelet Count 209 ×10^3/𝑚𝑚3
ESR 22 mm in 1st hr
RBS 5.30 mmol/L
S.Creatinine 0.7 mg/dL
Laboratory Investigations

32. Pre-operative
S.Albumin 3.00 g/L
S. Electrolytes Na- 139 mmol/L,
K- 4.4 mmol/L
Cl- 102 mmol/L
CXR P/A view Normal
HbsAg, Anti HCV, Anti HIV Negative
CEA 3 ng/mL
RT PCR for Covid-19 Negative
Laboratory Investigations

33. Small bowel GIST
Clinical diagnosis

34. After optimization of the patient and patient counselling ,
informed written consent was taken.
Then we planned for operation.
Management

35.  Date and Time: 28-03-2021 @10.00 AM
 Name of Operation: Exploratory laparotomy followed by en bloc resection of jejunum
with mesenteric mass with jejunojejunostomy & gastrojejunostomy.
 Name of Indication : Small bowel GIST
 Name of Anesthesia : G/A
 Name of Incision: Upper midline incision
 Name of Surgeons : Team SU-VI
Operation Note

36. With all aseptic
precautions, after proper
painting & drapping
abdomen was opened with
upper midline incision.
Operative Procedure

37. Mass involving the mesentery near
the mesenteric border of proximal
jejunum 30 cm from DJ measured
about 10×15 cm. A few firm enlarged
lymph nodes were present adjacent
to the mass.
No ascitic fluid was present.
Liver, Spleen and parietal peritoneum
was normal.
Operative Findings

39. Operative Procedure
About 50 cm portion of
jejunum with mesenteric
mass was resected.

40. About 50 cm portion of
jejunum with mesenteric
mass was resected.
Operative Procedure

41.  Size of lump involving jejunum and
mesentery was around 10×15 cm
 Proximal stump was about 15 cm
from the DJ junction.
 Jejunojejunostomy,
gastrojejunostomy was done.
Operative Procedure

42.  Size of lump involving jejunum and
mesentery was around 10×15 cm
 Proximal stump was about 15 cm
from the DJ junction.
 Jejunojejunostomy,
gastrojejunostomy was done.
Operative Procedure

43.  Size of lump involving jejunum and
mesentery was around 10×15 cm
 Proximal stump was about 15 cm
from the DJ junction.
 Jejunojejunostomy,
gastrojejunostomy was done.
Operative Procedure

44.  Size of lump involving jejunum and
mesentery was around 10×15 cm
 Proximal stump was about 15 cm
from the DJ junction.
 Jejunojejunostomy,
gastrojejunostomy was done.
Operative Procedure

45.  Size of lump involving jejunum and
mesentery was around 10×15 cm
 Proximal stump was about 15 cm
from the DJ junction.
 Jejunojejunostomy,
gastrojejunostomy was done.
Operative Procedure

46.  Size of lump involving jejunum and
mesentery was around 10×15 cm
 Proximal stump was about 15 cm
from the DJ junction.
 Jejunojejunostomy,
gastrojejunostomy was done.
Operative Procedure

47.  Size of lump involving jejunum and
mesentery was around 10×15 cm
 Proximal stump was about 15 cm
from the DJ junction.
 Jejunojejunostomy,
gastrojejunostomy was done.
Operative Procedure

48.  Size of lump involving jejunum and
mesentery was around 10×15 cm
 Proximal stump was about 15 cm
from the DJ junction.
 Jejunojejunostomy,
gastrojejunostomy was done.
Operative Procedure

49.  A pelvic drain was kept.
 After proper hemostasis and counting mops and gauge, abdomen was closed in layers.
 Specimen was sent for Histopathology
Operative Procedure

50. Resected Specimen

51.  On 1st POD- Vital signs were within normal limit.
 Urine output was normal .
 Drain tube collection-100ml
 Bowel sound - Absent
 On 2nd POD- Vital signs were within normal limit
 Urine output was normal .
 Drain tube collection-50ml
 Bowel sound - Present
Post Operative Outcome

52.  On 3rd POD- Vital signs and baseline investigations were within normal limit.
Drain tube collection-30 ml
 On 4th POD- Vital signs were within normal limit.
 Urine output was normal .
 Drain tube collection-10 ml
 Oral feeding started.
 On 5th POD- Vital signs were within normal limit.
 Drain tube and urinary cathter was removed.
 Check dressing was done.
Post Operative Outcome

53. Microscopic Description:
Shows wall of small intestine. The intestinal architecture is replaced by monotonous
population of atypical lymphoid cells forming a mass lesion. The lymphoid cells are of
mixed population. The tumour has invaded the whole thickness of the wall.
Histologic type : Non Hodgkins lymphoma
Histologic grade : Intermediate grade
Comment-
Ileal segment with mesenteric mass (resected)- Diffuse Non-Hodgkins lymphoma,
intermediate grade
D/D-Epitheloid GIST
Histopathology Report

54. After consulting with Oncology department ,
we advised the patient to do following investigations for further
management-
LCA
CD-117
CD-20
Oncology Department Consultation

55. • On 10th POD- Stitches removed and the
patient was discharged
• Patient was asked to follow up with the
reports at Department of Oncology , DMCH for
further management.
Follow Up and Advice
(Pictures used with consent)

56. Special thanks to
Department of Radiology, DMCH
Department of Anesthesia, DMCH
Department of Oncology, DMCH

57. Thank You

58. Surgery Unit – VI, DMCH