History
A 60-year-old lady with a history of neurofibromatosis, mechanical mitral valve replacement and atrial fibrillation on warfarin developed sudden onset postural dizziness upon getting out of bed. She subsequently passed a large amount of tarry stools. There was no haematemesis or coffee ground vomiting. She has good compliance with warfarin and denies any over-the-counter medications.
•Afebrile, pulse 110 bpm, BP 78/42mmHg, SaO2 98% on RA.
•Conjunctival pallor.
•Examination of the hands reveals no clubbing and normal-appearing palmar creases.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual, mechanical 1st heart sound.
•Her chest is clear on auscultation.
•Abdominal examination reveals a soft, non-tender abdomen, with no definite mass palpable.
•Per rectal exam: fresh melaena.
•No signs of oedema.
Investigations
•CBC:
–WBC 13.8 x 109/L;
–haemoglobin 3.6g/dL ← 6.8g/dL ← 10g/dL (baseline);
–platelets 441 x 109/L.
•Urea 15.3mmol/L.
•Creatinine 123μmol/L.
•INR 3.89.
•Liver function tests are grossly normal.
•CXR: no free gas under the diaphragm.
•ECG: sinus tachycardia with a rate around 110 to 120 bpm. No acute ST/T wave changes.
How would you manage this lady?
•Crystalloid fluid resuscitation and blood transfusion.
•Correct the INR with vitamin K and fresh frozen plasma.
•Urgent oesophagogastroduodenoscopy (OGD): a 1.2cm ulcerated submucosal mass next to the ampulla is seen.
What is your differential diagnosis for the mass?
•Gastrointestinal stromal tumour (GIST).
•Neuroendocrine tumour.
•Lymphoma.
•Pancreatic rest.
•Neurofibroma.
What imaging test would you order next?
Computed tomography of the abdomen and pelvis (Figures 14.1 and 14.2).
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Please describe what you see
An arterial enhancing lesion in D2 without features of intestinal obstruction is noted. There are no features suggestive of metastases.
What further investigations would you request?
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