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An unusual cause of melena
  1. K P Basavaraju1,
  2. K Armitage1,
  3. C R Hunt2,
  4. N K Ahluwalia3
  1. 1Department of Gastroenterolgy, Stepping Hill Hospital, Stockport, UK
  2. 2Department of Histopathology, Stepping Hill Hospital, Stockport, UK
  3. 3Department of Gastroenterolgy, Stepping Hill Hospital, Stockport, UK
  1. Correspondence to:
    Dr K P Basavaraju, Department of Gastroenterology, Stepping Hill Hospital, Stockport, UK; krishna.basavarajustockport.nhs.ukRobin Spiller, editor

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Clinical presentation

A 79 year old Caucasian male presented with a two week history of melena. His past medical history included hypertension, atrial fibrillation, and malignant melanoma. He was on warfarin. Examination demonstrated a palpable irregular liver edge and the presence of melena was confirmed on per-rectal examination. Routine bloods showed an admission haemoglobin of 76 g/dl and an international normalised ratio of 3.0. Warfarin was withheld and an oesophogastroduodenoscopy was performed.

Gastroscopy identified three ulcers with craters in the gastric fundus, the largest being approximately 2.5 cm in size (fig 1). A single ulcer (0.5 cm) was seen in the gastric antrum and an another ulcer (1.5 cm; fig 2) was seen in the second part of the duodenum. There were no stigmata of active bleeding. The above ulcers were biopsied. Figure 3 shows the gastric mucosa and submucosa (haematoxylin-eosin ×100) and fig 4 shows immunohistochemical staining of the gastric mucosa with HMB45, MART-1, and tyrosinase cocktail (×400).

Figure 1

 An ulcer in the gastric fundus.

Figure 2

 An ulcer in the second part of the duodenum.

Figure 3

 Gastric mucosa and submucosa (haematoxylin-eosin ×100).

Figure 4

 Immunohistochemical staining of the gastric mucosa with HMB45, MART-1, and tyrosinase cocktail (×400).

Question

What is the diagnosis?

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