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. 2025 Sep 29;20:107. doi: 10.1186/s13000-025-01709-z

Gastric endophytic gastrointestinal stromal tumor (GIST) as a rare cause of gastroduodenal intussusception: case report and literature review

Shengwei Ji 1, Weijie Chen 2, Beiwei Zhu 2, Maowei Pei 3,✉
PMCID: PMC12482829  PMID: 41024144

Abstract

Objectives

To report a rare case of adult gastroduodenal intussusception caused by a gastric gastrointestinal stromal tumor (GIST) and review its diagnostic and therapeutic approaches. 

Methods

We present a 68-year-old female with gastroduodenal intussusception secondary to a gastric GIST, diagnosed through combined endoscopy and computed tomography (CT). A systematic PubMed review identified 28 published cases, which were analysis for clinical presentation, imaging findings, and management strategies.

Results

The patient initially underwent laparoscopic-endoscopic cooperative surgery, which was unsuccessful and required conversion to open partial gastrectomy. Intraoperative findings confirmed a fundus mass extending into the duodenum, with histopathology confirming a low-risk GIST. Among the reviewed cases, all involved GISTs of gastric origin. Diagnostic evaluation consistently relied on CT and endoscopy, with surgical approaches varying based on tumor characteristics.

Conclusions

Gastric GISTs are a rare but clinically significant cause of adult gastroduodenal intussusception, typically necessitating surgical intervention. Multimodal imaging, particularly CT, plays a crucial role in preoperative diagnosis, while histopathological examination remains essential for definitive diagnosis and risk stratification. Treatment should be individualized based on tumor size, location, and patient factors.

Keywords: Gastroduodenal intussusception, Gastric tumor, GIST, Laparoscopy, Gastric resection

Introduction

Gastroduodenal intussusception is an extremely rare condition in adults. The primary etiologies include gastric tumors such as gastrointestinal stromal tumors (GISTs), carcinomas, lipomas, schwannomas, and leiomyomas, according to the literature [1]. A comprehensive literature review by Hsieh et al. [2] covering the past two decades identified gastric GIST to be the predominant cause, accounting for over half of reported adult cases. Here, we report a case of gastroduodenal intussusception caused by an endophytic gastric GIST in a 68-year-old female patient, and discuss its clinical manifestations, diagnosis, management, and prognosis in the context of existing literature.

Case description

A 68-year-old female patient was admitted to the Department of Gastroenterology with a 1-day history of nausea, hematemesis, and epigastric pain. Her medical history included hypertension treated with amlodipine 5 mg daily, cerebral infarction treated with aspirin 100 mg daily, diabetes controlled with metformin 0.5 g three times a day, and gallbladder stones treated intermittently with celecoxib.

Physical examination revealed signs of anemia without specific gastrointestinal-specific findings. The abdomen was soft, non-tender, with no guarding or rebound tenderness. No Masses were palpable. Neurological assessment showed grade 0 muscle strength in the right limbs and grade V- strength in the left limbs.

Laboratory findings showed severe anemia (hemoglobin 52 g/L [normal 115–150 g/L]; hematocrit 0.157 [normal 0.4–0.5]), mild leukocytosis (9.99 × 10⁹/L [normal 4.0–10.0 × 10⁹/L]), and normal C-reactive protein (< 5 mg/L). Tumor markers (CEA, CA19–9) were within normal range. Abdominal non-contrast computed tomography (CT) revealed a well-defined 5.4 cm × 4.8 cm × 4.2 cm intraluminal mass along the lesser curvature of the gastric body (Fig. 1). Gastroscopy demonstrated mucosall elevation in the gastric fundus. The tumor had caused invagination of the gastric cardia through the antrum and pylorus into the duodenum, resulting in gastric outlet obstruction. A definitive diagnosis of gastroduodenal intussusception was made. An attempted endoscopic reduction was unsuccessful (Fig. 2). Following consultation, the patient was transferred to our department for surgical management.

Fig. 1.

Fig. 1

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Intraluminal tumor in the gastric funds on CT. CT scan revealed the intraluminal tumor (arrow) formation of the gastric fundus on axial (a) and coronal (b). CT: computed tomography

Fig. 2.

Fig. 2

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Endoscopic appearance of the gastric mass. Showing tumor morphology observed during gastroscopy

Initial laparoscopic exploration revealed no intra-abdominal metastases. The attempted laparoscopic resection of the mass was unsuccessful. Subsequent laparoscopic-endoscopic cooperative surgery proved technically challenging. Considering the patient's poor clinical condition, we converted to open laparotomy for segmental resection. Intraoperative palpation confirmed that the gastric mass had become impacted through the pylorus into the duodenum. Anterior gastrotomy identified a solid, well-circumscribed intraluminal tumor in the gastric fundus with surface ulceration and necrosis. After intraoperative confirmation of gastroduodenal intussusception and successful surgical reduction, a circular radical excision of the mass was achieved with wide negative margins (R0 resection). The gastric wall defect was sutured in a transverse fashion in two layers. There was no tumor rupture during the surgery.

Histopathological examination revealed a 5cm×4cm×3cm spindle-cell morphology tumor (Fig. 3) with a mitotic rate of 2 per 50 high-power fields. Immunohistochemistry demonstrated positivity for CD34(Mouse Monoclonal Antibody, Clone BY134, Ready-to-Use, Hangzhou Biopin Biotechnology Co., Ltd.), DOG-1(Rabbit Monoclonal Antibody, Clone SP31, Ready-to-Use, Maixin Biotech Co., Ltd. (Fuzhou, China)), and CD117(Mouse Monoclonal Antibody, Clone YR145, Ready-to-Use, Maixin Biotech Co., Ltd. (Fuzhou, China)) (Figs. 4 and 5). The Ki-67(Rabbit Monoclonal Antibody, Clone BY084, Ready-to-Use, Hangzhou Biopin Biotechnology Co., Ltd.)labeling index approximately 3%, with retained mutated-type p53(Mouse Monoclonal Antibody, Clone DO-7, Ready-to-Use, Hangzhou Biopin Biotechnology Co., Ltd.) expression.

Fig. 3.

Fig. 3

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Macroscopic specimen of the excised tumor. Gross pathology measurement: 5 cm × 4 cm × 3 cm

Fig. 4.

Fig. 4

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Histological characteristics of the tumor (hematoxylin and eosin staining). a Low-magnification view (× 100); b High-magnification view (× 400)

Fig. 5.

Fig. 5

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Immunohistochemical (IHC) staining profile. a CD117-positive expression; b DOG1-positive expression. Both panels at × 100 magnification. CD: cluster of differentiation

The final pathological diagnosis was a low-risk GIST arising from the gastric body. The definitive clinical diagnosis was gastroduodenal intussusception secondary to the gastric GIST. The patient recovered uneventfully and was discharged on postoperative day 8. No recurrence or metastasis was observed during the 6-month follow-up period.

Discussion

Gastroduodenal intussusception is an extremely uncommon complication associated with gastric tumors, occurring when a tumor leads to telescoping of the gastric wall into the duodenum [3]. GISTs are uncommon mesenchymal neoplasms originating from the interstitial cells of Cajal, with an estimated annual incidence of 10–20 per million. Although the stomach constitutes the most frequent site (> 60%), followed by the small intestine (25–30%) and colon (5–15%) [4–7], gastroduodenal intussusception secondary to gastric GIST is exceptionally rare. To our knowledge, this entity is only documented in case reports. Our Literature review identified 28 adult cases of GIST-induced gastroduodenal intussusception. Table 1 compares the clinical characteristics of these published cases with the current presentation. The median age at diagnosis was 62 years (range: 23–95), with peak incidence occurring in the 9th decade of life (Fig. 6).

Table 1.

Summary the clinical characteristics of gastroduodenal intussusception caused by GIST in PubMed

Case NO Authors Date of publishing Country Age (year) Gender Clinical symptoms Tumor Location Tumor size (cm) Imaging Test Treatment
1 Siam et al. [55] 2008 Malaysia 29 M Abdominal pain and anaemia, nausea and vomiting, Antrum 6 × 6 EGD Laparotomy; Partial gastrectomy (Bilroth’s I)
2 Chan et al. [56] 2009 China 34 F Epigastric pain Fundus 6.5 × 4.4 CT; EGD Laparoscopic; wedge resection
3 Gyedu et al. [57] 2011 Ghana 59 F Intermittent vomiting Anterior wall 7 × 6 CT; US Laparotomy; wedge resection
4 Costi et al. [58] 2011 France 81 M Abdominal pain and anemia Posterior wall 4 × 3 CT; EGD laparoscopic; Atypical gastrectomy
5 Seok et al. [59] 2012 Korea 51 M Nausea, vomiting, melena and severe anemia Antrum 5.5 × 4.2 × 1.7 EGD; CT Laparotomy; Partial gastrectomy
6 Wilson et al. [60] 2012 Ireland 78 F Epigastric discomfort, vomiting and anorexia Distal body and antrumc 4.4 × 3.3 × 3.4 CT; EGD Endoscopic and laparoscopic; wedge resection
7 Rittenhouse et al. [61] 2013 USA 52 F Epigastric pain, vomiting Fundus 5 × 5 CT; EGD; US Laparoscopic; wedge resection
8 Anania et al. [62] 2013 Italy 63 F Epigastric discomfort, dyspepsia and bilious vomiting Fundus 19 × 11 × 9 CT; EGD; US Laparoscopic; wedge resection
9 Babannavar MSPB et al. [63] 2015 India 74 M Vomiting Posterior wall EGD; CECT Laparotomy; wedge resection
10 Yildiz et al.[64] 2016 Turkey 85 F Epigastric discomfort, nausea, vomiting and weight loss Fundus 6 × 5 CECT; US Laparotomy,subtotal gastrectomy and Roux and Y anastomosis
11 Komatsubara et al.[65] 2016 Japan 90 F vomiting Body 5 × 4.5 × 4 EGD; CT Laparotomy, wedge resection
12 Jameel et al. [66] 2017 India 65 F Epigastric pain, vomiting Posterior wall 6 × 6 × 4 EGD; CT Laparotomy, wedge resection
13 Yamauchi et al. [67] 2017 Japan 95 F vomiting and melena Posterior wall 4.2 × 3.9 CT; EUS Endoscopic; ESD
14 Zhou et al. [68] 2018 China 69 M Abdominal pain, nausea and vomiting Antrum 4.5 × 4 EGD; CT Laparoscopic; wedge resection
15 Ssentongo et al. [69] 2018 Ghana 85 F Epigastric pain dyspepsia Fundus 2.5 × 2.5 CT Laparotomy, wedge resection
16 De et al. [70] 2018 India 42 F Epigastric pain and vomiting Anterior wall 8 × 7 × 4 EGD; CT Laparotomy, wedge resection
17 Đokić et al. [71] 2019 Slovenia 62 M Vomiting, weight loss Body 7.5 × 5.5 × 4 CECT; US Laparotomy, wedge resection
18 Mohammed AA et al. [72] 2019 Iraq 65 F Vomiting, weight loss Body 45 × 21 EGD and biopsy; CT Laparotomy, Total gastrectomy, roux-en-y esophago-jejunostomy and jejunojejunostom
19 Michael et al. [73] 2021 Uganda 23 F Epigastric pain, vomiting Body 6 × 7 CECT; EGD Laparotomy; wedge resection
20 Arora E et al. [74] 2021 India 36 M Anemia, and melena Body 9.5 × 8.5 × 7.5 CT; EGD Laparoscopic; wedge resection
21 Hsieh YL et al. [75] 2021 China 84 F Postprandial fullness with nausea and vomiting Body 5.9 EGD; CT Endoscopic; ESD
22 Numpraphrut P et al. [76] 2022 Thailand 55 M Epigastric pain and vomiting Fundus 5.5 × 4.3 × 4 CT; EGD; EU Laparoscopic; wedge resection
23 Zhang W et al. [77] 2022 China 85 M Black stools; epigastric discomfort Body and antrum 5 × 3.5 EGD; CT laparoscopic exploration; Laparotomy; wedge resection
24 Nicola S et al. [78] 2022 Italy 36 M Melena and severe anaemia Fundus 11 × 4 EGD; CT Laparotomy; wedge resection
25 Singh K et al. [79] 2023 USA 72 ND abdominal pain, nausea and vomiting Body 5.6 × 5.3 EGD and biopsy; CT Endoscopic(Failure), Laparotomy, distal antrectomy (Billroth II)
26 Tagliaferri A R, Naseer M, Melki G, et al. [80] 2023 USA 85 M abdominal pain Body 5.6 × 5.3 EGD; CT Laparotomy; Distal gastrectomy (Billroth II)
27 Mujaheed Suleman et al. [81] 2024 Tanzania 75 F abdominal pain, weight loss Fundus 6 × 6 CT Laparotomy, wedge resection
28 Our case 2024 China 68 F Vomiting blood Fundus 5 × 4 × 3 EGD; CT Laparotomy; wedge resection
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Fig. 6.

Fig. 6

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Age distribution of patients with gastroduodenal intussusception secondary to gastric GISTs. GISTs: gastrointestinal stromal tumors

Gastroduodenal intussusception secondary to GISTs poses a diagnostic challenge due to nonspecific and variable clinical manifestations, frequently leading to initial misdiagnosis by the consulted physician. The rarity of this condition and diagnostic oversight often result in delayed identification at advanced stages. Presentations range from acute to chronic, featuring intermittent epigastric pain (mild to severe), nausea, vomiting, abdominal tenderness, palpable masses, weight loss, and gastrointestinal bleeding with anemia secondary to mucosal ulceration [8]. Symptom patterns correlate with tumor characteristics including size and location [4, 9], with concurrent pancreatitis representing an exceptionally unusual finding [10–12]. Our analysis demonstrates that symptomatic GISTs universally exceed 2 cm in diameter. Notably, all obstruction-causing tumors measured > 2 cm, with 89% exceeding 4 cm (literature review). As illustrated in Fig. 7, gastric GISTs predominantly localize the gastric body. The current case exhibited chronic manifestations including recurrent vomiting and progressive epigastric pain, potentially attributable to spontaneously reducible intussusception episodes.

Fig. 7.

Fig. 7

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Anatomical location distribution of gastric tumors. Showing tumor sites within the stomach

The preoperative diagnosis of GIST remains challenging due to nonspecific clinical presentations. Multiple imaging modalities—including ultrasonography, CT, magnetic resonance imaging (MRI), and endoscopy—facilitate the evaluation. CT demonstrates the highest diagnostic utility among these, with reported accuracy ranging from 58 to 100% [13]. Characteristic CT findings of intussusception include target signs or sausage-shaped masses along the longitudinal axis. On CT, GISTs are mainly isodense to minimally hypodense relative to the muscle layer. In response to effective treatment, GISTs decrease in size and become more homogenous with disappearance of nodules. CT optimally delineates tumor dimensions and anatomical relationships with adjacent organs, though limitations include difficulty distinguishing inflammatory adhesions from true organ involvement and determining the tumor origin. MRI complements CT evaluation, particularly for anorectal and hepatic metastatic GISTs [15]. Small GISTs typically demonstrate homogeneous arterial enhancement, while larger lesions show lobulated morphology and heterogeneous enhancement due to hemorrhage, necrosis, and cystic degeneration [14]. On MRI, GISTs appear isointense to minimally hypointense relative to muscle on T1-weighted sequences and hyperintense on T2-weighted images. Gastric endoscopy identifies bleeding sources and enables biopsy, though detection rates for submucosal/extraluminal GISTs remain low, often yielding false-negative biopsies. Endoscopic ultrasound (EUS) enhances mass characterization [16]. Ultrasound- or CT-guided fine-needle aspiration (FNA) provides histologic material for immunohistochemical confirmation, improving preoperative diagnosis [17]. However, biopsy is generally contraindicated in removable primary tumors due to risks of tumor rupture, hemorrhage, and dissemination. When biopsy is indicated, EUS-FNA is preferred for its diagnostic accuracy, safety profile, and low dissemination risk. Abdominal ultrasound may demonstrate classical intussusception features, though operator dependence limit reliability [12]. Figure 8 summarizes preoperative diagnostic approaches.

Fig. 8.

Fig. 8

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Diagnostic methodologies employed in the study cohort. Summary of clinical assessment techniques

Once diagnosed, management focuses on intussusception reduction and tumor resection to prevent recurrence. Advances in flexible endoscopy have broadened therapeutic indications. Available endoscopic resection techniques include enucleation, band ligation (EBL), submucosal dissection (ESD), submucosal excavation (ESE), tunneling endoscopic resection (STER), full-thickness resection (EFTR), and laparoscopic-endoscopic cooperative surgery (LECS). Endoscopic resection is particularly effective and safe for GISTs smaller than 2 cm. For GISTs measuring 2–5 cm, treatment selection depends on their muscularis propria location [18–21]. Polypoid lesions with a narrow stalk attachment are amenable to endoscopic enucleation. Those with a broad-based attachment may be attempted endoscopically but carry a higher failure risk. Centrally located gastric wall tumors or those protruding externally towards the serosa require alternative endoscopic approaches. When EFTR is technically challenging, LECS provides a safe alternative [22, 23].

Surgical resection with clear margins remains the gold standard treatment. Lymphadenectomy is generally unnecessary since gastric GISTs rarely metastasize to lymph nodes [24, 25], unless imaging or endosonographic findings suggest involvement. The surgical approach (endoscopic, laparoscopic, or open) depends on tumor location, adherence/invasion of adjacent structures, and the patient’s overall medical status (Fig. 9). Laparoscopic techniques, which are endorsed by NCCN Guidelines for expanding their roles, offer advantages including faster recovery, lower mortality, and reduced recurrence rates according to some studies [26]. While suitable for smaller tumors, concerns exist regarding potential tumor cell dissemination from capsular rupture with larger lesions, particularly during manipulation.

Fig. 9.

Fig. 9

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Surgical approaches utilized. Distribution of operative techniques

The impact of tumor size on laparoscopic feasibility remains debated. Evidence supports the safety and feasibility of laparoscopic resection for gastric GISTs ≤ 5 cm [27–29]. Furthermore, tumor size alone may not preclude laparoscopic wedge resection [30], and location may have minimal influence on approach selection [31]. Successful laparoscopic resections for tumors > 10 cm have been reported [32, 33]. Both Japanese [34] and Chinese [35] guidelines consider laparoscopic resection of GIST smaller than 5 cm to be safe when performed by experienced surgeons. Small posterior wall GISTs near the gastroesophageal junction may be enucleated to preserve function,taking advantage of their typical pseudocapsule. Surgical options, guided by tumor size, number, and location, include wedge resection, Billroth I/II partial gastrectomy (gastroduodenostomy or gastrojejunostomy), or total gastrectomy with Roux-en-Y reconstruction. Wedge resection was found to be the predominant technique in our literature review (Fig. 10). For duodenal GISTs, segmental resection with primary anastomosis is feasible if the lesion is small and > 2 cm from the ampulla of Vater. Tumors within 2 cm of the ampulla or adherent to adjacent organs necessitate pancreaticoduodenectomy (Whipple procedure). Meticulous technique to avoid capsular rupture and intra-abdominal tumor spillage is paramount to minimize recurrence risk [36], especially with larger tumors prone to peritoneal seeding due to elevated intratumorally pressure or reduced cellular adhesion. Surgeons must be prepared for prompt conversion to open surgery whenever necessary [37]. Robotic surgical systems can enhance feasibility and safety for complex resections [38–40], particularly for unfavorably located or larger upper gastrointestinal GISTs, by facilitating precise dissection and suturing reconstruction to mitigate rupture risk. In our case, we grasped the stomach and surrounding normal tissues, rather than the tumor itself, to prevent the tumor spreading during open resection. Figures 11 and 12 summarize surgical approach and scope selection based on tumor characteristics according to our review.

Fig. 10.

Fig. 10

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Surgical resection margins. Summary of surgical scope

Fig. 11.

Fig. 11

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Algorithm for surgical approach selection based on tumor size. Decision flowchart for operative technique

Fig. 12.

Fig. 12

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Algorithm for surgical scope determination based on tumor location. Decision flowchart for resection boundaries

Special consideration should be given to incidentally discovered gastric GISTs during bariatric surgery, which require careful balancing of oncological safety and gastric integrity preservation [41–43]. Small, low-risk GISTs can often be resected without altering the bariatric plan, with complete resection typically being curative [42]. However, tumors near critical anatomy (e.g., gastroesophageal junction) or those necessitating extensive resection may significantly modify the surgical strategy [41]. The decision-making process is complex, influenced by variable tumor size, location, and malignant potentia [43–45].

Histopathological (HP) examination, complemented by immunohistochemistry (IHC) and molecular analysis, is critical for differentiating mesenchymal tumors [46, 47]. Over 95% of GISTs demonstrate c-Kit mutations, typically confirmed by positive cluster of differentiation (CD)117 IHC staining. GISTs are also usually positive for CD34 and discovered on GIST1 (DOG1) [48], while frequently negative for S100, smooth muscle actin (SMA) and desmin, which are more specific to other stromal tumors (e.g., leiomyoma, melanoma, rhabdomyosarcoma, leiomyosarcoma). The key prognostic factors include tumor size, mitotic rate, primary site, and capsular integrity [26, 49, 50]. Tumors ≥ 10 cm, with a mitotic rate ≥ 5 per 50 high-power fields (HPF), non-gastric location, and intraoperative tumor rupture independently predict recurrence following complete resection. Well-defined molecular-morphological associations exist in GIST. While not universally applicable, morphological evaluation can help predict underlying molecular alterations in a subset of cases. These correlations guide pathologists in selecting appropriate molecular tests, thereby informing therapeutic decision-making and predicting treatment response [51].

Adjuvant therapy represents an important intervention for patients with intermediate or high-risk GIST after resection. A randomized controlled trial (RCT) demonstrated superior recurrence-free and overall survival with 3 years versus 1 year of adjuvant imatinib in high-recurrence-risk GIST [52]. Consequently, 3-year imatinib therapy is the established standard for high-risk disease [50]. The efficacy of extending imatinib beyond 3 years remains unproven and requires further investigation. Similarly, the role of sunitinib or regorafenib in the adjuvant setting lacks robust evidence. Neoadjuvant imatinib has shown efficacy in unresectable or metastatic GIST [53, 54], where tumor size reduction facilitates subsequent surgical resection and correlates with improved clinical outcomes.

While this study provides comprehensive clinical insights, several limitations should be acknowledged. Firstly, the literature review was restricted to PubMed-indexed English publications, potentially omitting relevant non-English case reports. Secondly, the retrospective nature of case analysis introduces inherent selection bias in the reviewed literature. Comparative analysis was constrained by heterogeneous reporting standards across case studies, particularly in surgical outcome documentation. Thirdly, long-term follow-up data (> 5 years) were unavailable for our case, limiting assessment of recurrence patterns. Besides, the single-center experience may not reflect global practice variations in GIST management. Future multicenter studies with standardized protocols would strengthen the evidence base.

Authors’ contributions

Maowei Pei and Shengwei Ji wrote the main manuscript text. Shengwei Ji do the operation and review the literature, prepared table. Weijie Chen collect and analyze the data, prepared Figs. 1, 2, 3, 4, 5, and 6. Beiwei Zhu collect and analyze the data, prepared Figs. 7, 8, 9, 10, 11, and 12. All authors reviewed the manuscript.

Funding

None.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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