Clinical presentation

A 42 year old previously healthy man presented with an eight hour history of retrosternal tightness. While clinical examination was unremarkable, his cardiac enzymes were raised and his electrocardiogram showed ST segment elevation in leads II, III, and aVf. He was diagnosed with an acute inferior myocardial infarction and received 1.5 million units of streptokinase over the next hour. His pain settled and he was comfortable overnight.

The following morning he developed epigastric pain and tenderness and vomited twice. His haemoglobin level dropped to 12 g/dl (15 g/dl on admission). Although overall he improved over the next 48 hours, he continued to vomit even though fasting. An upper gastrointestinal endoscopy was preformed and demonstrated the duodenal abnormality shown in fig 1.

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Figure 1

 Upper gastrointestinal endoscopy.

Question

What is the abnormality shown (fig 1) and what is the most appropriate course of subsequent treatment?

See page 102 for answer

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