Gastrointestinal stromal tumors (GISTs) are the most common nonepithelial solid neoplasms involving the alimentary tract. We report a case of cystic GIST with multiple cystic metastases. A 61-year-old man presented with upper abdominal pain for two months. Further evaluation revealed a large intra-abdominal cyst in the lesser sac and another cyst over the segment VII of the liver on imaging. Multiple intra-abdominal hydatidoses were suspected based on the imaging and its endemic nature in the geographical area. However, the hydatid serology was normal. In view of hemorrhagic cyst fluid, an intraoperative frozen biopsy of the cyst wall was done, which revealed features suspicious of a mesenchymal tumor. Sleeve gastrectomy with enbloc excision of the gastric cyst, excision of the hepatic cyst, and complete excision of multiple other intra-abdominal cysts were performed considering GIST as a possibility. Histology revealed a clear cell variant of GIST. Gastric GISTs primarily presenting as multiple intraabdominal cysts and of clear cell histological variants had never been reported in the literature. The patient was started on imatinib, and he has shown no evidence of recurrence after 12 months of follow-up. A high index of suspicion, intraoperative frozen section, meticulous surgery, and immunohistochemistry are all crucial for the effective management of atypical cases. GIST may be considered as a part of differential diagnosis in clinical scenarios with multiple intraabdominal cysts, especially in the equivocal setting.

Left renal vein (LRV) has been considered as the most suitable vein for proximal splenorenal shunt (PSRS), a commonly performed shunt for non-cirrhotic portal hypertension. Anatomical anomalies in LRV that can pose technical difficulty during shunt procedure are reported in 10% cases. We report a rare anomaly of LRV which precluded performance of standard end-to-side proximal splenorenal shunt and describe its management by performing an interposition end-to-end proximal splenorenal shunt. A 50-year-old female presented with recurrent episodes of upper gastrointestinal bleed for five years. She was pale and had a massive splenomegaly. There were no signs of encephalopathy. Upper gastrointestinal (UGI) endoscopy revealed three columns of grade 3 esophageal varices, large fundal varices and mild portal hypertensive gastropathy. Duplex ultrasound and contrast-enhanced computed tomography (CECT) of the abdomen was suggestive of non-cirrhotic portal fibrosis. She underwent an interposition end-to-end proximal splenorenal shunt with inferior branch of left renal vein. She developed partial shunt thrombosis at follow-up of 18 months and underwent balloon angioplasty and metallic stenting of shunt. She is doing well at 24 months follow-up with no recurrence of symptoms and a patent shunt. In conclusion, the presence of renal vein abnormalities does not preclude performance of PSRS with suitable modifications. A high index of suspicion is required to detect them preoperatively to avoid technical difficulties and to plan modifications of PSRS. Interposition end-to-end graft proximal splenorenal shunt is a valid option with good primary-assisted patency rate and clinical outcome.