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Special Feature
April 2013

Image of the Month—Quiz Case

Author Affiliations


Author Affiliations: Department of Surgery, Loyola University, Chicago, Illinois.

JAMA Surg. 2013;148(4):393. doi:10.1001/jamasurg.2013.300a

A 62-year-old woman with a medical history of gastroesophageal reflux disease, hypothyroidism, and remote bronchial tuberculosis presented to the emergency department with acute-onset bright red blood per rectum. She denied pain or change in bowel habits until she had large-volume loose bloody stools the day of presentation. She was anemic and hypotensive, requiring intensive care unit admission and multiple transfusions. Multiple diagnostic modalities were used including nuclear medicine bleeding scan, push enteroscopy, and double-balloon endoscopy. Findings were significant only for several nonbleeding gastric antral ulcers on esophagogastroduodenoscopy and rare, nonbleeding ascending colonic diverticula on colonoscopy. Blood was noted in the small intestine on endoscopy without an obvious lesion or source. A follow-up computed tomography enterography showed a 2-cm enhancing mass in the proximal small bowel as displayed in Figure 1.

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Figure 1. Computed tomography enterography revealing a 2-cm enhancing mass (arrow) in the proximal small bowel.

The patient underwent exploratory laparotomy with notable finding of a 3-cm mass approximately 10 cm distal to the ligament of Treitz. Intraoperative endoscopy failed to reveal any other possible source of her gastrointestinal bleed. The microscopic pathology of the resected mass is shown in Figure 2.

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Figure 2. Hematoxylin-eosin staining of cross-section of the small-bowel mass revealed normal-appearing acini and ducts (arrow) within the small-bowel wall (original magnification ×100).

What Is the Diagnosis?

A.  Lymphoma

B.  Heterotopic pancreas

C.  Leiomyoma

D.  Carcinoid