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Presented by Ralph Hruban, M.D. and prepared by Whitney Green, M.D.
Case 4: This 50 something year old presented with GI bleeding necessitating a pancreatoduodenectomy.
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1. Question
Week 576: Case 4
This 50 something year old presented with GI bleeding necessitating a pancreatoduodenectomy.images/Case4_image1RH.jpg
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images/Case4_image5RH.jpgCorrect
Answer: Vasculitis
Histology: Several duodenal ulcers are present. Deep to these ulcers, and even away from the ulcers are small arteries with fibrinoid necrosis. This necrosis was highlighted on a VVG stain.
Discussion: The vascular changes observed in this case are away from the ulcers, so they are not simply secondary to the ulcers. The vasculitis could represent a manifestation of a systemic vasculitis such as polyarteritis nodosa, or the vasculitis could be limited to this single organ. ANCA and other blood tests were all within the normal range, and the patient had no other systemic manifestations of vasculitis. While “single organ vasculitis” is the most likely diagnosis in this case, clinical follow-up for six months is needed to rule out the possibility that this is the first manifestation of a systemic vasculitis.
Reference(s):- Atisha-Fregoso et al, Clin Rheumatol, 2013; 32:1-6.
Incorrect
Answer: Vasculitis
Histology: Several duodenal ulcers are present. Deep to these ulcers, and even away from the ulcers are small arteries with fibrinoid necrosis. This necrosis was highlighted on a VVG stain.
Discussion: The vascular changes observed in this case are away from the ulcers, so they are not simply secondary to the ulcers. The vasculitis could represent a manifestation of a systemic vasculitis such as polyarteritis nodosa, or the vasculitis could be limited to this single organ. ANCA and other blood tests were all within the normal range, and the patient had no other systemic manifestations of vasculitis. While “single organ vasculitis” is the most likely diagnosis in this case, clinical follow-up for six months is needed to rule out the possibility that this is the first manifestation of a systemic vasculitis.
Reference(s):- Atisha-Fregoso et al, Clin Rheumatol, 2013; 32:1-6.
