Adherent thrombus from bleeding ulcer results in obstructing duodenal pseudotumor

Adherent Thrombus from Bleeding Ulcer Results in Obstructing Duodenal Pseudotumor Sanju K Balaram, MD, Bret T Murray, MD, Alan T Richards, MD, FACS, Creighton University School of Medicine, Omaha, NE Five days after admission for pneumonia, a 76-year-old man with severe chronic steroid-dependent obstructive pulmonary disease began complaining of diffuse abdominal pain, distention, nausea, and vomiting. Vital signs included a heart rate of 150 beats per minute, systolic blood pressure of 70, and a respiratory rate of 35 breaths per minute. His abdomen was markedly distended and tympanic. Bowel sounds were present and he was tender to palpation in the epigastrium without guarding or rigidity. Abdominal radiograph revealed a massively dilated stomach. His hemoglobin had dropped from 14 gm/dL on admission to 10.2 gm/dL. He had been given a two-unit transfusion of packed red cells. A nasogastric tube was placed with immediate resolution of the patient’s hemodynamic instability. A small amount of blood was aspirated. CT scan of the abdomen revealed a large mass in the duodenum with near complete obstruction (A). An upper GI series demonstrated a mushroom-shaped mass anchored by a narrow stalk in the second portion of the duodenum (B). Esophagogastroduodenoscopy revealed a normal stomach with a smooth, hemorrhagic mass obstructing the pylorus. Biopsies showed nonspecific inflammatory tissue. With a presumed duodenal tumor and unresolving gastric outlet obstruction, the patient was taken to surgery. A pedunculated mass measuring 8 cm was visualized in the duodenum (C). The mass was smooth and gelatinous with an opaque capsule. The stalk was present on the medial wall of the duodenum 5 cm proximal to the ampulla of Vater. A chronic duodenal ulcer was located next to the stalk. No active bleeding was present. Frozen section revealed fibrin, neutrophils, and blood. Histologic analysis of the mass, stalk, and base showed organized blood clot with no evidence of a polyp or malignancy. The patient was diagnosed with an adherent thrombus from a bleeding duodenal ulcer.

© 2001 by the American College of Surgeons Published by Elsevier Science Inc.

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