S4764 Recurrent Gastrointestinal Bleeding Due To a Jejunal Gastrointestinal Stromal Tumor: Diagnostic Utility of Enteroscopy in Small Bowel Evaluation

Introduction: Recurrent gastrointestinal (GI) bleeding with inconclusive upper and lower endoscopies is a diagnostic challenge and falls under the obscure overt GI bleeding category. Gastrointestinal Stromal Tumors (GIST) account for <1% of all GI tumors and are often located in the stomach or small intestine and can seldom present with a GI bleeding due to the mucosal ulceration. Enteroscopy provides valuable access to lesions beyond the reach of standard endoscopy. Case Description/Methods: A 74-year-old man with a history of intermittent nonsteroidal anti-inflammatory drug use presented with melena and a hemoglobin of 8.7 g/dL. Contrast computed tomography abdomen and pelvis showed no evidence of active hemorrhage. Initial esophagogastroduodenoscopy and colonoscopy revealed a 4 cm hiatal hernia but no definitive bleeding source. Patient was discharged but returned 1 week later with worsening Hgb of 6.8 g/dL and dizziness. A nuclear medicine bleeding scan showed tracer accumulation in the lower abdomen. Due to non-diagnostic upper endoscopy and colonoscopy, a Push Enteroscopy (PE) was pursued and identified a 2.5 cm ulcerated, friable, actively bleeding mass in the mid-jejunum. The lesion was tattooed and clipped for localization. Biopsy was nondiagnostic, but due to severe anemia and GI bleeding, segmental small bowel resection was performed with pathology confirming a 3.5 cm low-grade GIST with spindle and epithelioid morphology, 5 mitoses per 5 mm², 10% necrosis, and immunohistochemical positivity for DOG1, CD117, and SMA. Eventually patient was discharged with outpatient PET scan negative for metastasis and currently the patient is undergoing treatment with Imatinib (Tyrosine Kinase inhibitor) with normalized hemoglobin to 13.8 g/dl. Discussion: This case emphasizes the role of small bowel evaluation in patients with obscure and recurrent GI bleeding. While initial negative endoscopic findings can delay diagnosis, persistence in pursuing the bleeding source is essential. PE played a pivotal role by enabling visualization and localization of a bleeding jejunal GIST ultimately treated with surgical resection due to endoscopic localization and tattooing. Although rare, GISTs should be considered in the differential diagnosis of small bowel hemorrhage, particularly when conventional studies are unrevealing. Early identification of these lesions can prevent recurrent hospitalizations, reduce transfusion needs, and expedite definitive management. This case highlights the diagnostic yield and therapeutic implications of PE in evaluating obscure and recurrent GI bleeding.