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Incidental Apple-Core Lesion in the Duodenum. Ignore or Explore?
Journal Pre-proof Incidental Apple-Core Lesion in the Duodenum. Ignore or Explore? Miranda E. Gerrard, BS, Mohamad Mouchli, MD, Vikas Chitnavis, MD
PII: DOI: Reference:
S0016-5085(20)30166-9 https://doi.org/10.1053/j.gastro.2020.02.005 YGAST 63193
To appear in: Gastroenterology Accepted Date: 3 February 2020 Please cite this article as: Gerrard ME, Mouchli M, Chitnavis V, Incidental Apple-Core Lesion in the Duodenum. Ignore or Explore?, Gastroenterology (2020), doi: https://doi.org/10.1053/ j.gastro.2020.02.005. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 by the AGA Institute
Incidental Apple-Core Lesion in the Duodenum. Ignore or Explore? Miranda E. Gerrard BS1, Mohamad Mouchli MD2, Vikas Chitnavis, MD2 1
2
Virginia Tech Carilion School of Medicine
Virginia Tech Carilion School of Medicine, Division of Gastroenterology and Hepatology, Roanoke, VA
Authors’ contributions: M. Gerrard: reviewed medical records and data and participated in writing of the paper M. Mouchli: reviewed medical records and data and participated in the writing of the paper V. Chitnavis: reviewed medical records and data and participated in the writing of the paper
Address for correspondence:
Miranda E. Gerrard, BS Carilion Clinic 3 Riverside Circle Roanoke, VA, 24016 Phone: 540-449-5222 Email: [email protected]
Conflict of interests: We declare no conflicts of interest. The authors have no personal or financial disclosure
Question A 61-year old male presented to the emergency department with the chief complaint of nausea, vomiting, and right flank pain with radiation to the groin area for 2 days. The evening prior to presentation, he developed gross hematuria, lack of appetite, fevers, and chills. Past medical history was significant for hyperlipidemia, hypertension, and pulmonary embolism for which he was on warfarin. Family history was remarkable for an unknown malignancy on his maternal side. Physical exam was significant for a low-grade fever of 100.4 and right costovertebral tenderness. Complete blood count demonstrated leukocytosis of 12.8/ml and international normalized ratio (INR) measured 11.1. Urinalysis showed gross hematuria, nitrites, and WBC esterase. Computed tomography (CT) of the abdomen and pelvis exhibited hydronephrosis of the right kidney with perinephric stranding. An incidental duodenal mass was also identified on CT (Image 1). The patient was diagnosed with acute pyelonephritis and admitted to the progressive care unit for antibiotics and pain control. The Gastroenterology service was consulted to evaluate the incidental finding of a duodenal mass. After correcting the elevated INR, a fluoroscopic examination with contrast during the esophagogastroduodenoscopy revealed an apple-core lesion in the duodenum (Image 2). What is the diagnosis?
Answer: Submucosal duodenal hematoma secondary to supratherapeutic INR. Esophagogastroduodenoscopy (EGD) was performed the day after admission and did not reveal a mass, however a near-complete duodenal obstruction was identified in the second and third segments. The obstruction was determined to be a submucosal duodenal hematoma secondary to supratherapeutic INR (Image 3). Warfarin was discontinued and the patient was commenced on apixaban. It was recommended that esophagogastroduodenoscopy be repeated in several weeks. An intramural duodenal hematoma is not a common diagnosis and should be considered especially
in
patients
with
a
history
of
abdominal
trauma,
patients
undergoing
esophagogastroduodenoscopy (EGD) with tissue sampling, and patients with a hypocoagulable state [1]. The incidence was assumed to be 0.04% in patients on chronic anticoagulation [2]. It could cause cholangitis, pancreatitis, and hemorrhagic shock. Duodenal obstruction was reported in all documented cases but our patient was asymptomatic. Watchful waiting is the best treatment option since the hematoma generally resolves within a few weeks[1].
References 1. 2.
Niehues, S.M., et al., Intramural duodenal hematoma: clinical course and imaging findings. Acta Radiol Open, 2019. 8(4): p. 2058460119836256. Bettler, S., S. Montani, and F. Bachmann, [Incidence of intramural digestive system hematoma in anticoagulation. Epidemiologic study and clinical aspects of 59 cases observed in Switzerland (1970-1975)]. Schweiz Med Wochenschr, 1983. 113(17): p. 6306.
PII: DOI: Reference:
S0016-5085(20)30166-9 https://doi.org/10.1053/j.gastro.2020.02.005 YGAST 63193
To appear in: Gastroenterology Accepted Date: 3 February 2020 Please cite this article as: Gerrard ME, Mouchli M, Chitnavis V, Incidental Apple-Core Lesion in the Duodenum. Ignore or Explore?, Gastroenterology (2020), doi: https://doi.org/10.1053/ j.gastro.2020.02.005. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 by the AGA Institute
Incidental Apple-Core Lesion in the Duodenum. Ignore or Explore? Miranda E. Gerrard BS1, Mohamad Mouchli MD2, Vikas Chitnavis, MD2 1
2
Virginia Tech Carilion School of Medicine
Virginia Tech Carilion School of Medicine, Division of Gastroenterology and Hepatology, Roanoke, VA
Authors’ contributions: M. Gerrard: reviewed medical records and data and participated in writing of the paper M. Mouchli: reviewed medical records and data and participated in the writing of the paper V. Chitnavis: reviewed medical records and data and participated in the writing of the paper
Address for correspondence:
Miranda E. Gerrard, BS Carilion Clinic 3 Riverside Circle Roanoke, VA, 24016 Phone: 540-449-5222 Email: [email protected]
Conflict of interests: We declare no conflicts of interest. The authors have no personal or financial disclosure
Question A 61-year old male presented to the emergency department with the chief complaint of nausea, vomiting, and right flank pain with radiation to the groin area for 2 days. The evening prior to presentation, he developed gross hematuria, lack of appetite, fevers, and chills. Past medical history was significant for hyperlipidemia, hypertension, and pulmonary embolism for which he was on warfarin. Family history was remarkable for an unknown malignancy on his maternal side. Physical exam was significant for a low-grade fever of 100.4 and right costovertebral tenderness. Complete blood count demonstrated leukocytosis of 12.8/ml and international normalized ratio (INR) measured 11.1. Urinalysis showed gross hematuria, nitrites, and WBC esterase. Computed tomography (CT) of the abdomen and pelvis exhibited hydronephrosis of the right kidney with perinephric stranding. An incidental duodenal mass was also identified on CT (Image 1). The patient was diagnosed with acute pyelonephritis and admitted to the progressive care unit for antibiotics and pain control. The Gastroenterology service was consulted to evaluate the incidental finding of a duodenal mass. After correcting the elevated INR, a fluoroscopic examination with contrast during the esophagogastroduodenoscopy revealed an apple-core lesion in the duodenum (Image 2). What is the diagnosis?
Answer: Submucosal duodenal hematoma secondary to supratherapeutic INR. Esophagogastroduodenoscopy (EGD) was performed the day after admission and did not reveal a mass, however a near-complete duodenal obstruction was identified in the second and third segments. The obstruction was determined to be a submucosal duodenal hematoma secondary to supratherapeutic INR (Image 3). Warfarin was discontinued and the patient was commenced on apixaban. It was recommended that esophagogastroduodenoscopy be repeated in several weeks. An intramural duodenal hematoma is not a common diagnosis and should be considered especially
in
patients
with
a
history
of
abdominal
trauma,
patients
undergoing
esophagogastroduodenoscopy (EGD) with tissue sampling, and patients with a hypocoagulable state [1]. The incidence was assumed to be 0.04% in patients on chronic anticoagulation [2]. It could cause cholangitis, pancreatitis, and hemorrhagic shock. Duodenal obstruction was reported in all documented cases but our patient was asymptomatic. Watchful waiting is the best treatment option since the hematoma generally resolves within a few weeks[1].
References 1. 2.
Niehues, S.M., et al., Intramural duodenal hematoma: clinical course and imaging findings. Acta Radiol Open, 2019. 8(4): p. 2058460119836256. Bettler, S., S. Montani, and F. Bachmann, [Incidence of intramural digestive system hematoma in anticoagulation. Epidemiologic study and clinical aspects of 59 cases observed in Switzerland (1970-1975)]. Schweiz Med Wochenschr, 1983. 113(17): p. 6306.