Bleeding gastrointestinal stromal tumour of the stomach complicated by massive deep vein thrombosis – a management ilemma – a case report

Abstract

Cancer is a major risk factor for venous thromboembolism (VTE). Its treatment is an added risk factor for VTE. Malignancy results in a hypercoagulable state and hence DVT requiring anticoagulation. Cancer patients are at high risk of anticoagulant associated bleeding. Bleeding complications occur more with unfractionated heparin as compared to low molecular weight heparin. Standard medical treatment based on vitamin K antagonists is less effective and is associated with increased risk of bleeding in cancer patients. Low molecular weight heparin treatment has added advantages such as less sensitivity to drug interactions, lack of need for regular monitoring and has no problem of narrow therapeutic window as opposed to warfarin. Gastrointestinal stromal tumours (GIST) are the most common mesenchymal tumours of the gastrointestinal tract. The most common presentation is of gastrointestinal bleeding, pain and/or dyspepsia. We report  the case of a 67 year old hypertensive female patient who presented with a history of massive haematemesis and malaena. Upper gastrointestinal endoscopy confirmed a gastric tumour. She developed massive sudden swelling of the left lower limb whilst awaiting surgery. Doppler ultrasound scan confirmed an iliofemoral deep vein thrombosis (DVT). Inferior vena cava filter insertion was not possible due to non-availability. Coexistence of DVT needing anticoagulation and bleeding gastric GIST requiring urgent resection presented a management dilemna. Despite the risk, the patient was taken for an emergency tumor resection primarily to stop the bleeding and facilitate full anticoagulation therapy more safely. After 24 months follow up the patient had no evidence of recurrence of both the GIST and DVT.

Keywords: deep vein thrombosis, venous thromboembolism upper gastrointestinal bleeding, gastric tumour