This is a 49 year old African American male who presents with abdominal pain and chronic gastrointestinal bleeding with nausea and vomiting. A CT scan suggests a malignancy arising from the duodenum. Endoscopically we are examining the second part of the duodenum. There is evidence of malignant infiltration circumferentially involving the duodenum. The malignancy appears to arise from the duodenal bulb and extend down into the second portion of the duodenum. The tissue is friable but there are no gross ulcerations or evidence of active bleeding. The stomach is spared from malignant infiltration. Endoscopic ultrasound is performed with a linear endoscope and we can see evidence of malignant infiltration through the wall of the duodenum. The mass involves organs adjacent to the duodenum, including the pancreas. Enlarged hypoechoic malignant appearing lymph nodes are seen adjacent to the mass. The mass was staged as a T3N1 adenocarcinoma of the duodenum. The patient underwent a palliative gastrojejunostomy followed by chemotherapy and tolerated this well.
William R. Brugge, M.D., Harvard Medical School, Massachusetts General Hospital