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An unusual cause of obscure gastrointestinal bleeding
  1. C-M Tai1,2,
  2. H-P Wang3,
  3. J-C Hwang4,
  4. T-C Lee3,
  5. C-T Lee1,
  6. J-T Lin1
  1. 1
    Departments of Internal Medicine, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
  2. 2
    Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
  3. 3
    Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
  4. 4
    Departments of Pathology, E-Da Hospital/I-Shou University, Kaohsiung, Taiwan
  1. Correspondence to Dr J-T Lin, Department of Internal Medicine, E-Da Hospital and I-Shou University, 1, E-Da Road, Jiau-Shu Tsuen,Yan-Chau Shiang, Kaohsiung County 824, Taiwan; jawtown{at}ntu.edu.tw

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Clinical presentation

A 52-year-old man with end-stage renal disease and cirrhosis suffered from intermittent passage of melena of 2 months’ duration. Oesophagogastroduodenoscopy and colonoscopy did not reveal a bleeding lesion. He was referred to our hospital for balloon-assisted enteroscopy because of obscure gastrointestinal bleeding (OGIB). The laboratory findings were as follows: haemoglobin, 8.2 g/dl (normal range, 12.0–16.0 g/dl), platelet count, 102×103/μl (normal range, 150–400×103/μl), prothrombin time, 9.7 s (control, 10.6 s; international normalised ratio (INR), 0.91), activated partial thrombin time, 25.7 s (control, 31.3 s). Balloon-assisted enteroscopy via the oral route revealed a polyp measuring 0.5 cm in size, at the third portion of the duodenum. An ulcer with bleeding was also noted on the top of the polyp (fig 1). Endoscopic ultrasonography with a 12 MHz miniprobe (UM-DP12-25R; Olympus,Tokyo, Japan) revealed that the polyp was a mucosal lesion (fig 2).

Figure 1

A polyp with a bleeding ulcer was noted at the third portion of duodenum.

Figure 2

Endoscopic ultrasonography with a 12 MHz miniprobe revealed that the polyp was a mucosal lesion.

Question

What is the differential diagnosis and how do we manage this patient?

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Answer

Endoscopic mucosal resection (EMR) was performed to remove the bleeding polyp en bloc. We also utilised argon plasma coagulation (APC) to prevent delayed bleeding. Histopathological examination of the resected specimen showed a tubular adenoma with the presence of focal ulceration and formation of granulation tissue (fig 1A,B). Obscure gastrointestinal bleeding (OGIB) caused by a sporadic duodenal adenoma (DA) was thus diagnosed. The patient remained free from gastrointestinal bleeding during 4 months’ follow-up.

Figure 1

(A) Histopathological examination of the resected specimen showed a tubular adenoma with the presence of adenomatous glands, focal ulceration and formation of granulation tissue (H&E; original magnification, ×40). (B) Prominent capillaries (arrow) were found in the granulation tissue (H&E; original magnification, ×200).

The differential diagnosis of a duodenal polyp includes duodenal adenoma, Brunner’s gland tumour, inflammatory polyp, carcinoid tumour, or hamartoma, and the endoscopic appearance may be indistinguishable.1 DAs occur in 60–90% of patients with familial adenomatous polyposis,2 but sporadic DA, especially locating at the third portion of duodenum, is a rare entity. Most sporadic DAs are asymptomatic, but sometimes they may complicate with bleeding. Though bleeding from a small duodenal adenoma is unusual, the end-stage renal disease, cirrhosis and borderline platelet count in this patient may contribute to bleeding. EMR is a minimally invasive treatment modality for DAs, but bleeding is the most common complication. Ahmad et al reported a 33% incidence of bleeding in duodenal EMR.3 APC or clipping can be applied to prevent delayed bleeding.4 In this case, we demonstrated a small, bleeding duodenal adenoma which was successfully treated with EMR.

REFERENCES

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Footnotes

  • Robin Spiller, Editor

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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