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July 15, 2019

Image challenge: Once a colon, always a colon

What caused sudden-onset melena and associated orthostatic hypotension in a patient with an ulcer with a visible vessel?

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Gastroenterology clinical image challenge: A 68-year-old man presented to our emergency department with sudden-onset melena and associated orthostatic hypotension. Past medical history was notable for an esophagectomy with colonic interposition secondary to accidental caustic alkaline ingestion at 17, a history of unprovoked pulmonary embolism on warfarin anticoagulation and group 2–4 pulmonary hypertension on aspirin.

 

Physical examination was relevant only for mild tenderness in the epigastrium. Initial laboratory evaluation demonstrated a hemoglobin of 6.7 g/dL, an elevated international normalized ratio at 2.1 and a normal platelet count at 251 K/μL. Blood urea nitrogen and creatinine were also elevated (85 mg/dL and 1.88 mg/dL, respectively).

 

Nine months before his current presentation, he was evaluated for episodic dysphagia with associated prandial and postprandial chest discomfort and shortness of breath, which he reported had been gradually worsening over the past 20 years. The patient had undergone an exhaustive cardiopulmonary evaluation with cross sectional imaging and it was suspected that his symptoms were partially explained by retained food in his neoesophagus. A promotility agent was prescribed but no intervention was performed.

 

The patient was hemodynamically stabilized with aggressive fluid resuscitation and blood products. An urgent bedside esophagogastroduodenoscopy was performed. An ulcer with a visible vessel was identified in the duodenal bulb and treated with both mechanical clipping and cauterization. However, incidental findings were noted within the esophagus (figure).

 

Based on the clinical history, what is the most likely underlying etiology for the incidental findings in the esophagus?

 

To find out the diagnosis, read the full case in Gastroenterology.

 

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