Clinical presentation
In October 2004, a 69 year female patient presented with melena and anaemia (haemoglobin level 9 g/dl). The patient had been on warfarin due to construction of an aorto‐bifemoral graft because of an aortic aneurysm and an femoropopliteal bypass as a result of a stenosis of the left superficial femoral artery in 1996. Anticoagulation had been monitored regularly and international normalised ratio (INR) values had always been within the desired range of 2.5–3.5. On admission, INR was 3.1. The patient denied complains such as dyspepsia, NSAR intake, irregular bowel movements, or weight loss. Standard oesophagogastroduodenoscopy and colonoscopy revealed no signs of haemorrhage. As blood values remained stable after transfusion, the patient was discharged. In July 2005, the patient presented again with recurrent melena and anaemia (haemoglobin level 8 g/dl), and cardiovascular instability. Immediate enteroscopy with a side view endoscope (Pentax ED3440) revealed the findings shown in fig 1.
Figure 1 Endoscopic finding in the third part of the duodenum far beyond the papilla in the patient with occult gastrointestinal bleeding.
Question
What is the diagnosis?
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