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• W3005341483 abstract "Question: A 61-year-old man presented to the emergency department with the chief complaint of nausea, vomiting, and right flank pain with radiation to the groin area for 2 days. The evening before presentation, he developed gross hematuria, lack of appetite, fevers, and chills. Past medical history was significant for hyperlipidemia, hypertension, and pulmonary embolism for which he was on warfarin. Family history was remarkable for an unknown malignancy on his maternal side. Physical examination was significant for a low-grade fever of 100.4°F and right costovertebral tenderness. Complete blood count demonstrated leukocytosis of 12.8/mL and international normalized ratio (INR) measured 11.1. Urinalysis showed gross hematuria, nitrites, and WBC esterase. Computed tomography of the abdomen and pelvis exhibited hydronephrosis of the right kidney with perinephric stranding. An incidental duodenal mass was also identified on Computed tomography (Figure A). The patient was diagnosed with acute pyelonephritis and admitted to the progressive care unit for antibiotics and pain control. The gastroenterology service was consulted to evaluate the incidental finding of a duodenal mass. After correcting the elevated INR, a fluoroscopic examination with contrast during the esophagogastroduodenoscopy revealed an apple-core lesion in the duodenum (Figure B). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. An esophagogastroduodenoscopy was performed the day after admission and did not reveal a mass; however, a near-complete duodenal obstruction was identified in the second and third segments. The obstruction was determined to be a submucosal duodenal hematoma secondary to supratherapeutic INR (Figure C). Warfarin was discontinued and the patient was commenced on apixaban. It was recommended that esophagogastroduodenoscopy be repeated in several weeks. An intramural duodenal hematoma is not a common diagnosis and should be considered especially in patients with a history of abdominal trauma, patients undergoing esophagogastroduodenoscopy with tissue sampling, and patients with a hypocoagulable state.1Niehues S.M. Denecke T. Bassir C. Hamm B. Haas M. Intramural duodenal hematoma: clinical course and imaging findings.Acta Radiol Open. 2019; 8 (2058460119836256)PubMed Google Scholar The incidence was assumed to be 0.04% in patients on chronic anticoagulation.2Bettler S. Montani S. Bachmann F. [Incidence of intramural digestive system hematoma in anticoagulation. Epidemiologic study and clinical aspects of 59 cases observed in Switzerland (1970-1975)].Schweiz Med Wochenschr. 1983; 113: 630-636PubMed Google Scholar It could cause cholangitis, pancreatitis, and hemorrhagic shock. Duodenal obstruction was reported in all documented cases, but our patient was asymptomatic. Watchful waiting is the best treatment option because the hematoma generally resolves within a few weeks.1Niehues S.M. Denecke T. Bassir C. Hamm B. Haas M. Intramural duodenal hematoma: clinical course and imaging findings.Acta Radiol Open. 2019; 8 (2058460119836256)PubMed Google Scholar" @default.
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• W3005341483 date "2020-09-01" @default.
• W3005341483 modified "2023-09-27" @default.
• W3005341483 title "Incidental Apple-Core Lesion in the Duodenum: Ignore or Explore?" @default.
• W3005341483 cites W29285249 @default.
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• W3005341483 doi "https://doi.org/10.1053/j.gastro.2020.02.005" @default.
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