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Special Feature
April 20, 2009

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations:Surgical Department (Drs Fischer and Metzger), and Department of Pathology (Dr Nagel), Cantonal Hospital Lucerne, Lucerne, Switzerland.




Copyright 2009 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2009

Arch Surg. 2009;144(4):379. doi:10.1001/archsurg.2009.11-a

A previously healthy 48-year-old woman was admitted to the hospital with acute hematemesis and melena. A physical examination revealed that she was in good general health without any abdominal tenderness or pain on palpation and normal bowel sounds. Her vital signs showed a slightly reduced blood pressure (120/70 mm Hg) with tachycardia of 110 beats/min. Within a few hours, her hemoglobin concentration rapidly dropped from 111 g/L to 85 g/L and further to 74 g/L even after she received 2 red blood cell transfusions. An esophagogastroduodenoscopy did not show any bleeding lesions in the upper gastrointestinal (GI) system. Computed tomography finally revealed a round mass in the patient's left upper abdomen, probably in the jejunum. Because of her persistent anemic bleeding, the patient was taken to the operating room. Performing an explorative laparotomy, we found a large vascularized tumor 8 × 5 × 6 cm located 20 cm distal from the musculus suspensorius duodeni (Figure 1and Figure 2). We performed a segmental resection of the small bowel with excision of the palpable lymph nodes. Recovery in the patient was uneventful.

Figure 1.
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Hypervascularized tumor located 20 cm distal from the duodenojejunal flexure.

Figure 2.
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Macroscopic findings after resection and incision of the tumor and the small bowel (found inside the erosion).

What Is the Diagnosis?

A. Lymphoma

B. Adenocarcinoma of the small bowel

C. Gastrointestinal stromal tumor

D. Bleeding of the Meckel diverticulum