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JAMA Surgery Clinical Challenge
November 2014

Bleeding Abdominal Mass in a Patient With Genetic Cutaneous Disorder

Author Affiliations
  • 1Department of Surgery, San Joaquin General Hospital, French Camp, California
  • 2Department of Pathology, St Joseph’s Medical Center, Stockton, California
  • 3Department of Surgery, Sutter Gould Medical Foundation, Stockton, California
JAMA Surg. 2014;149(11):1203-1204. doi:10.1001/jamasurg.2013.5701

A 72-year-old man presented to the hospital after sustaining a fall, with prior generalized weakness and fatigue. He had been having recurrent gastrointestinal bleeding and melena during the past year. He reported a 6.75-kg weight loss during the past few months but did not have abdominal pain, nausea, vomiting, fevers, or chills. His surgical history was notable for a coronary artery bypass graft 9 months earlier and γ-knife resection of an acoustic neuroma 10 years ago.

Physical examination revealed a soft, nontender abdomen without obvious palpable masses. Inspection of the patient’s skin demonstrated multiple fleshy, soft cutaneous nodules (Figure 1A). The patient’s laboratory testing was only notable for anemia with a hemoglobin level of 10.4 g/dL (reference range, 12-16 g/dL). A prior extensive examination, including upper and lower endoscopy, upper gastrointestinal series with small-bowel follow-through, and capsule endoscopy did not reveal a diagnosis. A computed tomography image of the abdomen and pelvis is shown in Figure 1B.

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