S5985 Misleading Clues: When H. pylori Masks a Rare Tumor

Introduction: Helicobacter pylori gastritis is a common cause of upper GI bleeding (UGIB) in children; severe cases require blood transfusion and high dose proton pump inhibitors. While most UGIBs are related to ulcers or inflammation, gastrointestinal stromal tumors (GISTs) are a rare cause of bleeding in children. These tumors are insidious in presentation, commonly presenting with signs of chronic anemia. We present a case of an adolescent female with an UGIB who initially improved with treatment for H. pylori gastritis but had recurrent anemia prompting additional workup that led to a diagnosis of GIST. Case Description/Methods: A previously healthy 15-year-old female presented with symptomatic anemia including dizziness, fatigue, and melena. Workup revealed severe microcytic anemia, requiring transfusion. Stool H. pylori antigen was positive, and she was treated accordingly, with later confirmed eradication and symptom improvement. Six months later, she returned with recurrent symptoms and anemia requiring transfusion. Endoscopy showed multiple gastric nodules and an ulcer (Grade IIb by Forrest Classification) in the antrum. Biopsies from the nodules revealed mild chronic inflammation, negative for H. pylori. Imaging showed subepithelial gastric nodules and pulmonary hamartomas. Endoscopic ultrasound revealed numerous hypoechoic, and multilobulated subepithelial lesions in the gastric antrum. Pathology, immunohistochemistry, and genetic testing confirmed a wild-type GIST. She underwent a laparoscopic partial gastrectomy with Roux-en-Y reconstruction. While she tolerated the procedure, she continues to have anemia, and subsequent weight loss secondary to partial gastrectomy-associated early satiety. Discussion: This case features the importance of thorough evaluation in pediatric UGIB with severe anemia, even with H. pylori gastritis. This patient’s GIST exhibited typical pediatric features, but with the addition of pulmonary hamartomas, meeting criteria for rare Carney’s triad, and history of H. pylori. Although H. pylori is linked to gastric cancer, its role in the pathogenesis of pediatric GIST is unclear. Although H. pylori infection is typically asymptomatic, it is reasonable to consider endoscopic evaluation and/or further imaging in patients with UGIB presenting with severe anemia to screen for GISTs, regardless of H. pylori status.