Case Snippets 170 Indian Journal of Gastroenterology 2005 Vol 24 July - August gastrointestinal stromal tumors in a patient with von Recklinghausen’s disease. J Gastroenterol 2002;37:947-53. 3. Liu SW, Chen GH, Hsieh PP. Collision tumour of the stom- ach: a case report of mixed gastrointestinal stromal tumour and adenocarcinoma. J Clin Gastroenterol 2002;35:332-4. 4. Nakamura Y, Munemura C, Yashima K, Fujise M, Hosoda A, Kawasaki H, et al. A case of von Recklinghausen dis- ease accompanied with duodenal gastrointestinal stromal tu- mor and carcinoma in adenoma of the sigmoid colon. Nippon Shokakibyo Gakkai Zasshi 2002;99:1339-44. 5. Attoub S, Rivat C, Rodrigues S, Van Bocxlaer S, Bedin M, Bruyneel E, et al. The c-kit tyrosine kinase inhibitor ST1571 for colorectal cancer therapy. Cancer Res 2002;62:4879-83. Correspondence to: Dr Sudish Kumar, C/o Dr S De Bakshi, 41 Lake Temple Road, Kolkata 700 029. E-mail: scmdbakshi@yahoo.co.in, drsudish@yahoo.com Acknowledgments: We acknowledge Dr S Roy and Dr A Borges, Consultant Pathologists, Roy and Tribedi Pathology Laborato- ries, Park Street, Kolkata in helping with the CD117 and CD34 tests Received August 19, 2004. Accepted November 28, 2004 Gastrointestinal bleed after leeching in a patient on aspirin therapy Naveen Kumar, Rajat Mohindra, Bishav Mohan, G S Wander Department of Medicine, Dayanand Medical College and Hospital, Ludhiana Leeches (Hirudo medicinalis) have been used in health care for their property of bloodletting. Bleed occur- ring from the site of leech attachment has been well documented. We report a 50-year-old man who was on aspirin therapy for coronary artery disease, and presented with GI bleed after leech treatment for his knee pain. [ Indian J Gastroenterol 2005;24:170] L eeches have been used in health care since ancient times. 1 The leech salivary gland produces substances like hirudin ( with antithrombotic property) and platelet aggregation inhibitor, which are responsible for bleed occurring after leech treatment. 1 Bleed from site of leech attachment is a well-known complication of leech treatment. 1 A 50-year-old male with coronary artery disease, who had undergone coronary artery bypass graft and was on aspi- rin 150 mg OD and atenolol 50 mg OD for several months, presented with vomiting of 100-150 mL of blood. He was a non-smoker, non-alcoholic and there was no history of intake of any other drugs. On examination the patient was conscious and oriented but pale. There were a few marks over his right knee, but no other mucocutaneous lesion. Investigations: hemoglobin 8 g/dL, PCV 32% and plate- let 200,000/mm³. Coagulation profile and serum biochemistry did not reveal any abnormality. Endoscopy showed erosive gastritis and presence of altered blood in the stomach. The patient was managed with proton pump inhibitors and was transfused one unit of blood. He recovered uneventfully. On reviewing the history it was found that the patient had got leeches applied over his right knee for pain, twice over a period of four days, and developed GI bleed few hours after the second application. Michalsen et al 2 reported that leeches showed promise in the treatment of knee pain. 3 In villages of India, leeches are used for treatment of many conditions including knee pain. Our patient devel- oped GI bleed after applying leeches over his knee for pain. Endoscopy showed erosive gastritis. This patient was on aspirin, which is well known to cause erosive gastritis and thus GI bleed. But in view of the occurence of GI bleed few hours after leech therapy, we believe that leech therapy could have played a precipitating role in the GI bleed. Blackshear and Ebener 3 showed that medicinal leeching did not produce any alteration in the sys- temic coagulation profile. However, there is no in- formation on synergistic effect of aspirin and leech hirudin. With leeches playing an important role in conditions like repair of graft skin flaps, breast reconstruction, post phlebotic syndrome, 1 and knee pain, 2 studies are required to substantiate the risk of systemic bleed due to leech hirudin when com- bined with an antiplatelet agent. References 1. Adams SL. The medicinal leech, a page from Annelids of Internal Medicine. Ann Intern Med 1988;109:399-405. 2. Michalsen A, Klotz S, Ludtke E, Mocbus S, Spahn G, Dobos GJ. Effectiveness of leech therapy in osteoarthritis of the knee. A randomized controlled trial. Ann Intern Med 2003;139:724-30. 3. Blackshear JL, Ebener MK: Leeching, hirudin and coagula- tion tests. Ann Intern Med 1994;121:151-2. Correspondence to: Dr Mohan, Assistant Professor, Hero DMC Heart Institute, Ludhiana 141 001. E-mail: god_naveen@yahoo.com Received August 24, 2004. Accepted September 12, 2004 Complete gastric duplication cyst Sompal Singh, Ruchika Gupta, A K Mandal Department of Pathology, Maulana Azad Medical College, New Delhi 110 002 We report a 13-year-old boy who was detected to have an abdominal mass on ultrasonography. A pos- sibility of tuberculous lymph nodes was considered in view of history of pain, low fever, and anorexia. Histology of the excised mass showed complete gastric duplication cyst. [Indian J Gastroenterol 2005;24:170- 171]