doi:10.1016/j.jemermed.2007.11.111 Clinical Communications: Adults UNUSUAL ETIOLOGY OF EPIGASTRIC PAIN Rita Slim, MD,* Tarek Smayra, MD,† Cyril Tohme, MD,‡ Elia Samaha, MD,* Cesar Yaghi, MD,* and Raymond Sayegh, MD* *Department of Gastroenterology, †Department of Radiology, and ‡Department of General Surgery, Hotel-Dieu de France Hospital, Beirut, Lebanon Reprint Address: Rita Slim, MD, Department of Gastroenterology, Hotel-Dieu de France Hospital, Beirut, Lebanon e Abstract—Background: Epigastric pain is a common presenting complaint encountered in urgent care settings. Although peptic, biliary, and pancreatic pathologies are the most frequent findings, other rare diagnoses also can be found. Objectives: We report an unusual case of acute epigastric pain in which abdominal ultrasound was of great support in revealing the diagnosis. Case Report: A 64-year- old man presented to the Emergency Department after rapid onset of acute epigastric pain. Abdominal ultrasound showed a multi-cystic heterogeneous mass between the stomach and the liver. Abdominal computed tomography scan confirmed the gastric origin of the mass and showed torsion signs. Urgent laparotomy was performed with tu- mor excision. The diagnosis of pedunculated exophytic gastric stromal tumor was made and long-term follow-up was ar- ranged. Conclusions: Acute presentation revealed the pres- ence of the tumor, which was excised surgically. © 2011 Elsevier Inc. e Keywords— epigastric pain; torsion; GIST INTRODUCTION Gastrointestinal stromal tumors (GIST) were described in 1983 as a mesenchymal neoplasm closely related to the interstitial cells of Cajal (1). Diagnosis of GIST relies on standard histological examination. In a typical case, the diagnosis is definitively established when CD34 and c-Kit are positive while alpha-smooth muscle actin and S-100 are negative (2). Cystic stromal degeneration and stromal hemorrhage represent prominent features of GIST with spindle cell type. We describe a case of acute epigastric pain due to the pedicle torsion of an exophytic gastric stromal tumor, asymptomatic before this acute presentation. CASE REPORT A 64-year-old man with an unremarkable past medical history presented with acute abdominal pain. Sixteen hours before admission, he reported an acute epigastric pain of rapidly increasing intensity unrelated to meals, with no referred pain. There were neither changes in bowel habits nor signs of gastrointestinal hemorrhage. His clinical examination revealed stable hemodynamics with a temperature of 36.9°C (98.4°F) axillary, pulse 70 beats/min, blood pressure 130/80 mm Hg, and respira- tory rate 18 breaths/min. The heart and lungs were nor- mal on auscultation, and abdominal examination showed localized epigastric tenderness with a negative Murphy sign. Routine laboratory data were normal, including blood count and cardiac and liver enzymes. Electrocar- diogram and chest radiograph were also normal. Abdominal sonography showed a 6-cm heterogeneous multi-cystic abdominal mass located between the stom- ach and the left lobe of the liver (Figure 1). Abdominal computed tomography (CT) scan revealed a solid mass attached to the anterior wall of the stomach with torsion signs (Figure 2). RECEIVED: 30 September 2007; FINAL SUBMISSION RECEIVED: 5 November 2007; ACCEPTED: 16 November 2007 The Journal of Emergency Medicine, Vol. 40, No. 5, pp. e93– e95, 2011 Copyright © 2011 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$–see front matter e93