Case Presentation
An 87-year-old woman with a past medical history significant for
duodenal ulcers, atrial fibrillation on rivaroxaban, smoking history
with COPD, not on home oxygen therapy, chronic generalized pain, and
fibromyalgia on NSAIDs and opioids analgesics, presented to the hospital
with the chief complaint of black stools and dysphagia to solids. The
patient reported a loss of appetite, weight loss of about 10 lbs, and
insomnia. She denied any family history of cancer.
On admission, the patient was febrile and her vitals were within normal
limits. The physical examination was remarkable for conjunctival pallor.
Her abdomen was soft, non-tender, and non-distended, and normal bowel
sounds were heard on auscultation. Her complete blood count was
remarkable for normocytic anemia with a hemoglobin level of 10.7 g/dL
and a mean corpuscular volume (MCV) of 87 fL. The comprehensive
metabolic panel and coagulation profile were relatively normal. Iron
studies demonstrated serum iron 45 mcg/dL, total iron binding capacity
(TIBC) 291 mcg/dL, iron saturation 9 %, and ferritin 12 ng/mL, which
was consistent with iron deficiency anemia. Due to the presence of
dysphagia, melena associated with weight loss, and iron deficiency
anemia, esophagogastroduodenoscopy (EGD) was ordered. EGD revealed
presbyesophagus, a small hiatal hernia, erosive gastritis, and multiple
large ulcers located in the duodenal bulb, and the second and third
parts of the duodenum. The first and second portions of the duodenum
were deformed. Biopsies of the stomach and duodenum were obtained, and
the patient was started on omeprazole 40 mg twice a day. Rivaroxaban was
held in the setting of acute upper gastrointestinal (GI) bleeding.
The results of the stomach biopsy revealed mild inactive gastritis with
no intestinal metaplasia or dysplasia. Helicobacter pylori were
not detected. The duodenal ulcer biopsy showed atypical lymphoid
infiltration shown in Figures 1a and 1b.