Shrestha Ashish Lal, Shrestha Girishma
Department of General Surgery, United Mission Hospital, Tansen, Palpa, Nepal.
Department of Pathology, Patan Academy of Health Sciences, Lagankhel, Kathmandu, Nepal.
Case Rep Surg. 2018 Jun 5;2018:1320107. doi: 10.1155/2018/1320107. eCollection 2018.
Gastrointestinal stromal tumor (GIST) of the ileum is not a common differential to consider in the management of acute right iliac fossa (RIF) pain and tenderness. Finding of a normal-looking appendix intraoperatively should arouse the surgeon to explore further and look for other unanticipated pathologies. We present a case, clinically diagnosed as acute appendicitis and intraoperatively found to be an ulcerated ileal GIST.
A 28-year-old female without previous comorbidities presented to the emergency unit with sudden pain around the umbilicus that later migrated and localized to the RIF for one day. There was associated intermittent fever and anorexia without urinary symptoms. Abdominal examination revealed guarding and rebound tenderness at RIF. Examination by 2 senior surgeons at different points of time, the same day, made a clinical diagnosis of acute appendicitis. Ultrasonogram (USG) was inconclusive. At laparotomy through Lanz incision, the appendix was found to be normal and no other pathology was identified on walking bowel up to 3 ft proximal to ileocecal junction (ICJ). Just when closure was thought of, an ulcerated lesion could be seen through the medial aspect of the incision. On further exploration, a 7 × 5 cm ulcerated lesion arising from the antimesenteric border of the ileum was noted with localized interloop hemoperitoneum and inflammatory exudates. Ileal segmental resection anastomosis was done with peritoneal toileting. The lesion was subsequently reported to be an ulcerated malignant GIST.
The commonest cause of RIF pain with localized peritonitis is an acutely inflamed appendix. Dilemma arises when the appendix is found to look normal. Further exploration is indicted to not miss other findings.
回肠胃肠道间质瘤（GIST）在急性右下腹（RIF）疼痛和压痛的处理中并非常见的鉴别诊断。术中发现外观正常的阑尾时，外科医生应进一步探查，寻找其他意想不到的病变。我们报告一例病例，临床诊断为急性阑尾炎，术中发现为溃疡性回肠GIST。
一名28岁无既往合并症的女性因脐周突发疼痛就诊于急诊科，疼痛随后转移并局限于右下腹一天。伴有间歇性发热和厌食，无泌尿系统症状。腹部检查发现右下腹有压痛和反跳痛。同一天，两位资深外科医生在不同时间进行检查，临床诊断为急性阑尾炎。超声检查（USG）结果不明确。通过兰氏切口进行剖腹手术，发现阑尾正常，在向回盲部（ICJ）近端3英尺的肠管探查中未发现其他病变。就在考虑关闭切口时，通过切口内侧可见一个溃疡性病变。进一步探查发现，回肠对系膜缘有一个7×5厘米的溃疡性病变，伴有局限性肠袢间腹腔积血和炎性渗出物。进行了回肠节段切除吻合术并清理了腹腔。随后报告该病变为溃疡性恶性GIST。
RIF疼痛伴局限性腹膜炎最常见的原因是阑尾急性炎症。当发现阑尾外观正常时就会出现困境。需要进一步探查以避免漏诊其他发现。
