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Special Feature
Sep 2011

Image of the Month—Quiz Case

Author Affiliations


Author Affiliations: Department of General Surgery, Division of Vascular Surgery, Johns Hopkins University, Baltimore, Maryland.

Arch Surg. 2011;146(9):1101. doi:10.1001/archsurg.2011.215-a

A 90-year-old woman with a history of end-stage renal disease secondary to hypertensive nephrosclerosis who underwent hemodialysis, a colectomy with end ileostomy for diverticulitis, and an endovascular aneurysm repair 6 years prior in another institution for a 6-cm infrarenal abdominal aortic aneurysm with an Ancure endograft (Guidant Corp, Menlo Park, California) presented with episodes of melena evident in her ileostomy bag. The aneurysm had increased more than 2 cm in diameter during the past 2 years. In the same institution, she had undergone 2 prior endovascular repairs with AneuRx limb extensions (Medtronics Inc, Minneapolis, Minnesota) placed in the right iliac artery for a type I distal endoleak that eventually occluded. She had adequate collateral flow requiring no revascularization of the right lower extremity. An intravenous contrast computed tomographic scan showed a large endoleak in an 8-cm aneurysmal sac. During an examination, it was determined that the patient had significant abdominal tenderness with minimal guarding. She was tachycardic but normotensive. She underwent an esophagogastroduodenoscopy (Figure 1).

Image not available

Figure 1. Esophagogastroduodenoscopy demonstrating endograft material seen at the base of a duodenal diverticulum. The arrow indicates the stent struts.

What Is the Diagnosis?

A.  Peptic ulcer

B.  Ampullary cancer

C.  Aortoduodenal fistula

D.  Duodenitis