A 73-year-old man was hospitalized for cerebral trauma. While in the
hospital, he passed tarry stool and developed anemia. He then suddenly had
severe hemorrhage and went into shock. Emergent upper gastrointestinal tract
endoscopy revealed several shallow, geographical ulcers with coagula in the
second and third parts of the duodenum ([Fig. 1]).
One of the ulcers had an exposed vessel that was bleeding heavily ([Fig. 2]). We stopped the bleeding by administering
hypertonic saline with epinephrine and clipping the vessel. The next day, more
exposed vessels were detected, and new bleeding points appeared. The hemorrhage
reoccurred and the ulcers grew larger and deeper every day. New punched-out
ulcers were also detected ([3 a – c]). The patient tested
positive for serum cytomegalovirus (CMV) antigenemia and ganciclovir was
administered. Although we attempted endoscopic hemostasis, we could not stop
the hemorrhage completely, and the patient underwent surgery. Nuclear inclusion
bodies were observed in the resected specimens. The patient was diagnosed as
having hemorrhagic duodenal ulcers caused by CMV infection, and treatment with
ganciclovir was continued. Following surgery and treatment with ganciclovir,
scarring developed in the ulcers ([Fig. 4]), and
the patient tested negative for serum CMV antigenemia. Since then, the patient
has not passed tarry stool and there has been no progression of anemia. He is
likely to develop CMV-related disease because of his compromised status and
major lesions in the stomach and colon caused by the CMV infection
[1].
Fig. 1 Duodenum (third part):
shallow, geographical ulcers.
Fig. 2 Ulcer containing an
exposed vessel that was bleeding heavily.
Fig. 3 A new punched-out ulcer.
No exposed vessel is seen. b The ulcers became
increasingly deeper daily. c New exposed vessels.
Fig. 4 Scarring of the ulcers
following surgery and ganciclovir treatment.
A search of the literature indicated that CMV lesions in the
duodenum are rare, and hemorrhagic duodenal ulcers because of CMV infection are
even more rare [2]
[3]. Ulcers
related to CMV infection present in a variety of forms, for example, punched
out, geographical, circular, longitudinal, etc. [4]. When
a compromised host has bleeding in the alimentary tract and an ulcer with an
atypical shape, CMV infection should be included in the differential
diagnosis.
Endoscopy_UCTN_Code_CCL_1AB_2AZ_3AC
