A jejunal GIST presenting with obscure gastrointestinal bleeding and small bowel obstruction secondary to intussusception.

A 68-year-old man with episodes of overt obscure gastrointestinal (GI) bleeding was investigated with multiple upper and lower GI endoscopies, CT enterography and capsule endoscopy, but no cause was found. He then presented acutely with small bowel obstruction. A laparotomy revealed complete small bowel obstruction secondary to jejunal intussusception over a 4 cm intraluminal polyp. Following resection and primary anastomosis, histology revealed that the polyp was a GI stromal tumour (GIST). This is an exceptionally uncommon presentation of a rare tumour. It is surprising that this tumour was not detected by CT enterography and not seen on capsule endoscopy. Immunohistochemistry and mutation analysis of the GIST suggested that it had a low risk of metastatic disease, but a high risk of recurrence. Staging CT scans did not reveal evidence of distal spread. The patient is currently receiving 3 years of chemotherapy with imatinib.

The importance of cystoscopy and bladder biopsy in women with refractory overactive bladder: the urogynaecologist's point of view?

OBJECTIVES: To assess the sensitivity, specificity, positive and negative predictive value of cystoscopy and the clinical value of bladder biopsy in women with refractory overactive bladder (OAB) symptoms. STUDY DESIGN: Prospective observational study carried out in a tertiary referral urogynaecology unit in London. Consecutive women with OAB resistant to pharmacotherapy who underwent cystoscopy, hydrodistention and bladder biopsy were studied. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of cystoscopy as well as histological findings for chronic cystitis were evaluated. RESULTS: 106 women aged 22-91 years were studied. Histopathology showed chronic cystitis in 94 women, follicular cystitis 3, acute and chronic cystitis in 2, transitional cell carcinoma in 6 and no abnormality in 1 woman. Trabeculations and increased vascularity were the most common cystoscopic findings, seen in 71% and 72% of women respectively. Haemorrhages on first filling and haemorrhages on refilling had specificities of 86.6% and 80% respectively for chronic cystitis. Their sensitivities were 9.8% and 13.1% respectively. Trabeculations and increased vascularity had sensitivities of 68.1% and 68.1% and their specificities were 11.6% and 4.5% respectively. Trabeculations, increased vascularity, haemorrhages on first filling and haemorrhages on refilling all had a PPV over 80% for chronic cystitis. CONCLUSIONS: More than 90% of women with refractory OAB symptoms have chronic cystitis on histopathology. Cystoscopy alone is useful, but not always adequate to diagnose chronic cystitis. Antibiotic therapy in those women might be beneficial before starting anticholinergics. Larger randomised controlled trials are mandatory to confirm our hypothesis.