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.