Hrev_master [page 80] [Emergency Care Journal 2018; 14:7448] Emergency Care Journal 2018; volume 14:7448 A 74-year-old alert woman presented to the Emergency Department for abdominal pain, vomit, diarrhea and low grade fever. She had a blood pressure of 120/60 mmHg, a pulse rate of 106 bpm and O2 saturation of 100%. Physical examination showed abdominal distension, diffuse tenderness but without rebound ten- derness. Routine blood tests showed elevation of white cell blood count (18.4×109/L), increase of serum C-reactive protein (45.4 mg/dL) and procalcitonin (17.95 mg/dL). In the suspicion of an intestinal occlusion a radiographic study of the abdomen was per- formed; the radiography in erect view showed a huge gas-fluid col- lection with an irregular superior aspect and a gas-fluid level; entrapped gas bubbles were also evident below the gas-fluid niveau (Figure 1). A chest plain film was normal. A contrast- enhanced computed tomography (CT) of the abdomen, immediate- ly performed, detected a mass with a thin rim enhancement, gas and fluid-like content on scans (Figure 2). A communication with the bowel was supposed but not definitively demonstrated. Provisional differential diagnosis included a giant inflammatory diverticulum and perforation of a duplication intestinal cyst. The patient was thereafter operated on a laparotomy; surgical explo- ration revealed a 24 cm exophytic cavitated mass fistulized to the small bowel, which were resected. Histology in a solid area showed a proliferation of bland spindle cells (Figure 3), positive for CD117 and DOG-1 at immunohistochemistry. The final diag- nosis was exophytic gastrointestinal stromal tumor (GIST) of the small bowel with extensive cystic changes due to coagulative necrosis, with low mitotic activity, high risk.1 Large GISTs show often cystic change at presentation; approximately 50% of them are fistulized to the gastrointestinal tract at the diagnosis.2 Cystic appearance with a thin contrast-enhanced rim on CT scans is rare and usually found in rapidly growing GISTs.3 Differential diagno- sis of an abdominal cavitated lesion includes more common causes like abscess, large diverticulum, duplication intestinal cyst or pan- creatic pseudocyst perforated in the bowel. Nevertheless a GIST with cystic changes and gastrointestinal fistulization should be also considered in the preoperative diagnosis. Detection of the Torricelli-Bernoulli sign2 (i.e. presence of a nondependent intratu- moral gas collection directed towards the necrotic orifice on axial imaging), can suggest the correct diagnosis. Correspondence: Sergio Savastano, Department of Radiology, San Bortolo Hospital, v.le F. Rodolfi 37, 36100 Vicenza, Italy. Tel.: +39.0444.753490 – Fax: +39.0444.753839. E-mail sergio.savastano@aulss8.veneto.it Key words: Gastrointestinal stromal tumour; Radiological features; Gastrointestinal imaging. Contributions: the authors contributed equally. Conflict of interest: the authors declare no potential conflict of interest. Funding: none. Received for publication: 27 March 2018. Revision received: 21 May 2018. Accepted for publication: 28 May 2018. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright S. Savastano et al., 2018 Licensee PAGEPress, Italy Emergency Care Journal 2018; 14:7448 doi:10.4081/ecj.2018.7448 Gastrointestinal stromal tumor of the small bowel mimicking a gas-fluid collection Sergio Savastano,1 Luca Boi,1 Emanuele S.G. d’Amore2 1Department of Radiology; 2Department of Pathology, San Bortolo Hospital, Vicenza, Italy Figure 1. A huge gas-fluid collection at the left flank is evident on plain radiography of the abdomen (erect view); several gas bub- bles are appreciable below the gas-fluid level. Non -co mmerc ial us e o nly [Emergency Care Journal 2018; 14:7448] [page 81] References 1. Miettinen M, Makhlouf H, Sobin LH, et al. Gastrointestinal stromal tumors of the jejunum and ileum: a clinicopathologic, immunohistochemical, and molecular genetic study of 906 cases before imatinib with long-term follow-up. Am J Surg Pathol 2006;30:477-89. 2. Sandrasegaran K, Rajesh A, Rydberg J, et al. Gastrointestinal stromal tumors: clinical, radiologic, and pathologic features. AJR Am J Roentgenol 2005;184:803-11. 3. Kumar A, Jakhmola CK, Chauhan SS, et al. Atypical presenta- tion of gastrointestinal stromal tumor masquerading as a large duodenal cyst: A case report. Int J Surg Case Rep 2015;9:123- 6. Images in Emergency Figure 2. Contrast-enhanced CT. (A) The gas-fluid collection shows a thin peripheral rim; (B) Coronal reformation. CT scans did not demonstrated an intraperitoneal fluid collection (not shown). Figure 3. Histology shows showing a proliferation of bland spin- dle cells with low mitotic activity.Non -co mmerc ial us e o nly