An unusual case of duodenal beaking

Abstract

A 35-year-old female presented with complaints of several episodes of malaena and frank blood in the stools for the past 1 year. The frequency of these episodes had increased in the past 2 months. The patient complained of extreme weakness and palpitations. There was no history of abdominal pain, nausea, vomiting or haematemesis. There was no history of fever, jaundice, weight loss or constipation. Physical examination was unremarkable except for the presence of severe pallor. Digital rectal examination revealed black tarry stools staining the glove. There was no palpable growth; first degree haemorrhoids were visible at the 3 o'clock position; no active bleeding was discernible. Her haemoglobin was 4 g dl−1, packed cell volume 12.5%, total leukocyte count 7900 cells mm−3and platelet count 5.34×105 mm−3. Peripheral smear showed features of anaemia. Total serum bilirubin was 2.5 mg dl−1 (direct bilirubin 1.2 mg dl−1). The rest of the liver function tests were within normal limits. HBsAg (the surface antigen of the hepatitis B virus) was negative and human immunodeficiency virus was non-reactive. A chest radiograph demonstrated mild cardiomegaly and the lung fields were clear. Colonoscopy was within normal limits. An upper gastrointenstinal endoscopy was performed, which showed a normal stomach and first part of duodenum. The endoscope could not be negotiated into the third part of the duodenum. A barium meal examination was done for further evaluation of the upper gastrointestinal tract. Two radiographs of an upper gastrointestinal barium series are shown (Figure 1). Figure 1 (a) Barium meal upper gatsrointestinal tract: smooth narrowing or “beaking” at the junction of the second and third parts of the duodenum, with mucosal folds running parallel to the lumen and a small C-loop of the duodenum. (b) Barium ...