A 78 year-old male presented to an outside institution with dizziness and abdominal pain.

The patient is a seventy-three year-old male originally from the Greek island of Cephalonia. He presented to an outside institution with dizziness and abdominal pain. An esophagogastroduodenoscopy (EGD) was performed. This study revealed multiple gastric ulcers, none with active bleeding. He was transfused with two units of packed red blood cells and discharged. After having "tarry stools" the patient returned five days later, again with dizziness. A hematocrit measured at this second visit was eighteen percent. A second EGD was performed which showed, in addition to the non-bleeding ulcers, a one centimeter duodenal mass and fresh blood. Colonoscopy revealed a non-bleeding polyp. During this second visit, he was transfused with six units of packed red blood cells. A computed tomography scan revealed "an enhancing cystic mass in the duodenum." Subsequently, the patient was transferred to the Johns Hopkins Hospital for further work-up and definitive treatment.

He has no history of prior ulcers or GI illnesses. He has occasional heartburn, particularly at night. He does not use non-steroidal anti-inflammatory medications, aspirin, or herbals.

Three-vessel coronary artery disease.
Hypercholesterolemia.
Descending thoracic aortic aneurysm (4x5cm, cross-section).
Abdominal aortic aneurysm (3cm, greatest dimension).
Cerebral vascular accidents (3), with residual right arm weakness.
Benign prostatic hypertrophy

Coronary Artery Bypass Graft, three vessels (1990)
Abdominal Aortic Aneurysm (1990's)
Thoracotomy for pneumonia (approximately 35 years prior)

No history of GI illness.

He lives with his wife of 52 years near their children and grandchildren. They came from Greece in 1985 after he retired from a job as a butcher. He quit a lifetime of smoking cigarettes in 1990 but still drinks strong Greek coffee and Ouzo daily. There is no history of illicit drug use.

At the time of transfer from the outside hospital

Pantoprazole (Protonix)
Escitalopram (Lexapro)
Tamsulosin (Flomax)
Sublingual nitroglycerin
Oxazepam (Serax)
Temazepam (Restoril)
Aluminum and Magnesium Hydroxide (Maalox, Milk of Magnesia)

No known drug allergies.

At the time of transfer from the outside hospital

No abdominal pain. No nausea or vomiting. Bowel movements are once per day, not bloody or melanotic. No loss of consciousness or acute neurologic changes.

• Pleasant male patient speaks minimal English.
• Vital signs: T=37.3 C, HR=70, BP=146/64, O2 saturation 98% on RA.
• Head and Neck: Sclerae anicteric, mucous membranes moist
• Lungs: Clear to auscultation bilaterally
• Cardiovascular: Regular rate, II/VI systolic ejection-type murmur
• Abdomen: Soft non-tender, non-distended. Bowel sounds present. Well-healed midline incision. Stool negative for occult blood.
• Extremities: No edema in bilateral lower extremities. Dorsalis pedis pulse 2+.

WBC 8,800, Hct 31.1, Plt 192,000, K 3.4, Cr 0.8, Total Bili 0.5, LFT: within normal limits.

Leftward QRS axis, sinus rhythm, delayed precordial R wave.

Computed tomography scan was performed at the time of transfer to JHH (Images 1-5)

Image 1 - axial volume rendered CT image of the abdomen with iv contrast shows normal antrum and pylorus of stomach.

Image 2 - axial CT image of the abdomen with iv contrast shows small mass in the duodenum with enhancing rim.

Image 3- axial CT image of the abdomen with iv contrast shows mass in the duodenal lumen.

Image 4 - coronal oblique CT image of the abdomen with iv contrast shows mass in the duodenal lumen. mass is cystic in the center and has enhancing rim.

Image 5 - coronal oblique CT image of the abdomen with iv contrast shows mass in the duodenal lumen.

After the transfer to The Johns Hopkins Hospital, the patient was stable and did not require any further blood transfusions. The patient was evaluated by cardiology and determined to have a relatively low risk for major perioperative cardiac morbidity. The patient was taken for a procedure 5 days after his transfer to The Johns Hopkins Hospital.

What is the next procedure for evaluation of the abnormal findings?

What is your differential diagnosis?