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CLINICAL PRESENTATION
An 84-year-old man presented at our institution with tarry stools and epigastric pain for 1 day without nausea or vomiting. A medical history included a percutaneous coronary angioplasty (2 years previous) and chronic obstructive airways disease. On physical examination, the patient demonstrated mild tenderness in the epigastrium; however, no mass was palpable. Laboratory data revealed mild normocystic and normochronic anaemia (Hb 11.3 g/dl and Hct 32.9%). A plain abdominal x ray showed a normal gas pattern. An upper gastrointestinal endoscopy revealed a giant fold invaginated into the pyloric orifice originating from halfway down the lesser curvature of the stomach. This prevented the advancement of the endoscope as well as visualisation of the antrum (fig 1). A barium meal examination revealed a dilated stomach and an intramural mass lesion over the bulb of the duodenum (fig 2).
Acknowledgments
This article has been adapted from Chen Y-Y, Yen H-H, Soon M-S. Upper gastrointestinal bleeding with a difficult endoscopy Gut 2007;56:1528