ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Grace Elta and Robert J. Fontana, Section Editors
An Unusual Cause of Iron Deficiency Anemia Q2
Ken-Sheng Cheng,1,2 Tsung-Wei Chen,3 and Jen-Wei Chou1,2 1 3
web 4C/FPO
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58
Q1
School of Medicine, 2Division of Gastroenterology and Hepatology, Department of Internal Medicine, and Department of Pathology, China Medical University Hospital, Taichung, Taiwan
Question: A 31-year-old female doctor with a history of hyperthyroidism and iron deficiency anemia presented to our hospital because of black stool for 3 days. She was diagnosed having iron deficiency anemia 10 years ago. Positive occult blood in stool was also found sometimes. She previously underwent esophagogastroduodenoscopy (EGD), but it was normal. Iron supplement was prescribed. Physical examination showed pale conjunctivae but without mucocutaneous pigmentation. Laboratory tests showed a hemoglobin level of 6.5 g/dL. EGD, colonoscopy, and abdominal computed tomography–angiography all failed to detect a bleeding lesion. Thus, midgastrointestinal bleeding was suspected. Capsule endoscopy demonstrated some blood clots in the proximal jejunum. Antegrade double-balloon enteroscopy (DBE) disclosed a pedunculated polyp with nodular and erosive surface, measuring 3 1.5 cm in diameter, in the proximal jejunum (Figure A). Moreover, the pedunculated polyp had a long and thick stalk. Close observation by endoscopy revealed the presence of diffusely scattered white spots on the surface of the polyp. What is your diagnosis of this jejunal polyp? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.06.002
Gastroenterology 2014;-:e1–e2 DIS 5.2.0 DTD YGAST59176 proof 28 October 2014 12:09 pm ce
59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 1: Solitary Peutz-Jeghers Type Hamartomatous Polyp
web 4C/FPO
117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
We decided to resect the polyp endoscopically. First, we applied an endoloop to loop the base of the polyp (Figure B). Second, we used 2 hemoclips to clamp the stalk of the polyp (Figure C). Finally, we successfully performed a total polypectomy of the polyp by using an electrosurgical snare (Figure D). Histopathologic examination of the resected polyp showed dilated glands devoid of atypia, separated by bundles of smooth muscle fibers, which are thick in the center of the lesion and thinner on the periphery, confirming a diagnosis of hamartomatous polyp (Figure E; stain: hematoxylin and eosin; original magnification, 100). A solitary Peutz-Jeghers (PJ) type hamartomatous polyp is a rare disease in the gastrointestinal tract, mostly in the stomach and the duodenum.1 It is usually considered to be either a variant of PJ syndrome or a separate entity.1 A few reports have described its endoscopic features—an irregularly lobular or nodular surface—whereas adenomas often show a regularly nodular or granular surface.2 Because of the malignant potential, a solitary PJ-type hamartomatous polyp should be removed endoscopically or surgically.3 To our knowledge, this is the first case of jejunal solitary PJ type hamartomatous polyp treated with endoscopic polypectomy using DBE.
References 1. 2. 3.
Jamaludin AZ, Telisinghe PU, Yapp SK, et al. Solitary duodenal hamartomatous polyp with malignant transformation: report of a case. Surg Today 2009;39:527–532. Suzuki S, Hirasaki S, Ikeda F, et al. Three cases of solitary Peutz-Jeghers-type hamartomatous polyp in the duodenum. World J Gastroenterol 2008;14:944–947. Chen YY, Chen TS, Chen YF. Asymptomatic multiple gastric and duodenal tumors. Gastroenterology 2013;145:e7–e8.
e2 DIS 5.2.0 DTD YGAST59176 proof 28 October 2014 12:09 pm ce
175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232
An Unusual Cause of Iron Deficiency Anemia Q2
Ken-Sheng Cheng,1,2 Tsung-Wei Chen,3 and Jen-Wei Chou1,2 1 3
web 4C/FPO
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58
Q1
School of Medicine, 2Division of Gastroenterology and Hepatology, Department of Internal Medicine, and Department of Pathology, China Medical University Hospital, Taichung, Taiwan
Question: A 31-year-old female doctor with a history of hyperthyroidism and iron deficiency anemia presented to our hospital because of black stool for 3 days. She was diagnosed having iron deficiency anemia 10 years ago. Positive occult blood in stool was also found sometimes. She previously underwent esophagogastroduodenoscopy (EGD), but it was normal. Iron supplement was prescribed. Physical examination showed pale conjunctivae but without mucocutaneous pigmentation. Laboratory tests showed a hemoglobin level of 6.5 g/dL. EGD, colonoscopy, and abdominal computed tomography–angiography all failed to detect a bleeding lesion. Thus, midgastrointestinal bleeding was suspected. Capsule endoscopy demonstrated some blood clots in the proximal jejunum. Antegrade double-balloon enteroscopy (DBE) disclosed a pedunculated polyp with nodular and erosive surface, measuring 3 1.5 cm in diameter, in the proximal jejunum (Figure A). Moreover, the pedunculated polyp had a long and thick stalk. Close observation by endoscopy revealed the presence of diffusely scattered white spots on the surface of the polyp. What is your diagnosis of this jejunal polyp? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.06.002
Gastroenterology 2014;-:e1–e2 DIS 5.2.0 DTD YGAST59176 proof 28 October 2014 12:09 pm ce
59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to the Clinical Challenges and Images in GI Question: Image 1: Solitary Peutz-Jeghers Type Hamartomatous Polyp
web 4C/FPO
117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174
We decided to resect the polyp endoscopically. First, we applied an endoloop to loop the base of the polyp (Figure B). Second, we used 2 hemoclips to clamp the stalk of the polyp (Figure C). Finally, we successfully performed a total polypectomy of the polyp by using an electrosurgical snare (Figure D). Histopathologic examination of the resected polyp showed dilated glands devoid of atypia, separated by bundles of smooth muscle fibers, which are thick in the center of the lesion and thinner on the periphery, confirming a diagnosis of hamartomatous polyp (Figure E; stain: hematoxylin and eosin; original magnification, 100). A solitary Peutz-Jeghers (PJ) type hamartomatous polyp is a rare disease in the gastrointestinal tract, mostly in the stomach and the duodenum.1 It is usually considered to be either a variant of PJ syndrome or a separate entity.1 A few reports have described its endoscopic features—an irregularly lobular or nodular surface—whereas adenomas often show a regularly nodular or granular surface.2 Because of the malignant potential, a solitary PJ-type hamartomatous polyp should be removed endoscopically or surgically.3 To our knowledge, this is the first case of jejunal solitary PJ type hamartomatous polyp treated with endoscopic polypectomy using DBE.
References 1. 2. 3.
Jamaludin AZ, Telisinghe PU, Yapp SK, et al. Solitary duodenal hamartomatous polyp with malignant transformation: report of a case. Surg Today 2009;39:527–532. Suzuki S, Hirasaki S, Ikeda F, et al. Three cases of solitary Peutz-Jeghers-type hamartomatous polyp in the duodenum. World J Gastroenterol 2008;14:944–947. Chen YY, Chen TS, Chen YF. Asymptomatic multiple gastric and duodenal tumors. Gastroenterology 2013;145:e7–e8.
e2 DIS 5.2.0 DTD YGAST59176 proof 28 October 2014 12:09 pm ce
175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232
![[Monosymptomatic endemic sprue as a cause of iron deficiency anemia].](/assets/img/hold.png)
