Clinical presentation

A 60 year old man was admitted to our hospital with dehydration and fever, suggestive of the beginning of an Addisonian crisis. The pituitary had been resected for a prolactinoma 20 years previously. The patient could not take his hormone substitution medication due to severe gastroenteritis with nausea and vomiting. Blood pressure of 80/40 mm Hg, haemoglobin of 20 mg/dl, and haematocrit of 60% revealed haemoconcentration. Gastroscopy was performed to assess the upper gastrointestinal tract and showed that the longitudinal folds of the duodenum were covered by fibrinous erosions (fig 1A). Histopathological examination revealed an erosion with loss of superficial epithelial, inflammatory cells (neutrophils), necrotic epithelium, and fibrin. One week following treatment, endoscopy showed resolution of the lesions with flattening of the folds but no residual erythema or erosions. Histology now presented a normal duodenal mucosa with regular crypts and villi and no signs of inflammation (fig 1B).

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Figure 1

 Endoscopic and histological appearance of the mucosal lesion before (A) and after (B) treatment.

Question

What was the pathophysiology of the mucosal damage and how should it be treated?

See page 1234 for answer

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