88 Proc. roy. Soc. Med. Volume 68 February 1975

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In conclusion, it must be emphasized that there are far commoner causes for upper gastrointestinal hemorrhage and jaundice than carcinoma of the duodenum. However, this organ is now completely accessible both endoscopically and radiologically and these diagnostic aids coupled with awareness of the condition will inevitably lead to earlier diagnosis and more effective treatment.

anastomosis performed. The resected ileum showed two longitudinal ulcers, one of which had perforated. Histologically, occasional giant cell granulomas and a mixed inflammatory cell infiltration including numerous eosinophils were in keeping with a diagnosis of Crohn's disease. In November 1973, this patient required 131I therapy for a recurrence of thyrotoxicosis, and at the same time there was an exacerbation of his pretibial myxcedema. Since then he has been symptom free, requiring only monthly injections of vitamin B12. There has been a considerable reduction of his exophthalmos and pretibial myxcedema.

REFERENCES Bosse G & Neely J A (1969) American Journal of Roentgenology 107, 111 Paltalunan J G, Mayo C W & Dockerty M B (1964) American Journal of Surgery 108, 13 Sakker S & Ware C C (1973) British Journal of Surgery 60, 867 Whipple A 0, Parson W L & Mullens C R (1935) Annals of Surgery 102, 763

Pernicious An$mia, Thyrotoxicosis, Pretibial Myx6edema and Terminal Ileitis with Free Perforation E V Cox MD FRCP and D M Humphreys MRCP (The Royal Berkshire Hospital, Reading) F S, man aged 45 History: Presented in April 1967 aged 38 with the symptoms of anemia of four months' duration. A diagnosis of pernicious anemia was confirmed by the following investigations: macrocytic aneemia (Hb 6.8 g/100 ml, PCV 19 %, MCV 105 p,m3), megaloblastic erythropoiesis on examination of the sternal marrow, histamine fast achlorhydria on test meal, atrophic gastritis on gastric biopsy, serum B 12

Pernicious anaemia, thyrotoxicosis, pretibial myxoedema and terminal ileitis with free perforation.

88 Proc. roy. Soc. Med. Volume 68 February 1975 6 In conclusion, it must be emphasized that there are far commoner causes for upper gastrointestinal...
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