The colonoscopy revealed moderate sigmoid diverticulo-sis, three small colonic polyps and prominent internal hemorrhoids. These findings were not thought to explain his microcytic anemia or melena. Panendoscopy revealed a 3.5 cm, ulcerated, submucosal mass in the third portion of the duodenum, just beyond the ampulla of Vater (Figure 1).
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Figure 1) Image taken from an abdominal computed tomography scan revealing a large, hypoattenuating structure in the third portion of the duodenum (arrow)
This lesion was thought to explain both his chronic microcytic anemia and his melena, and a malignancy was suspected. Multiple superficial biopsies were taken, which were nondiagnostic. There was no endoscopic evidence to suggest Helicobacter pylori, and its presence was not sought. An abdominal computed tomography scan was obtained (Figure 2), which revealed a mass in the third portion of the duodenum, without any adjacent pancreatic lesions, liver lesions or intra-abdominal lymphadenopathy. The patient was referred for endoscopic ultrasound (EUS).
Figure 2) Endoscopic appearance of the large, ulcerating mass in the third portion of the duodenum