A 45-year-old Saudi male presented with a clinical picture of gastric outlet obstruction. Endoscopy showed pyloric stenosis with nonspecific inflammatory changes on biopsy. Ultrasound and computed tomography (CT) scan of the upper abdomen persistently demonstrated a mass in the head of the pancreas. Barium studies of the upper gastrointestinal tract showed markedly narrowed first part of the duodenum. On laparotomy, the pancreas was found to be normal, while a mass was present in the proximal part of the duodenum. Biopsy of the mass revealed a picture of duodenal tuberculosis. This case report points out the limitations of clinical evaluations and investigations in diagnosing duodenal tuberculosis and stresses the value of laparotomy and tissue diagnosis.
Case ReportA 45-year-old Saudi male was admitted to King Khalid University Hospital (KKUH) for dyspepsia, epigastric pain, anorexia, and weight loss of nine months' duration. He lost about 20 kg of weight within nine months. His complaints started with jaundice accompanied by dyspepsia and vomiting after meals. There was no change in bowel habits, but he gave a history of dark colored urine and clay colored stools. Jaundice resolved with outdoor treatments in different clinics and he was ultimately admitted to KKUH nine months after the appearance of jaundice.While under investigation, he left the hospital against medical advice and was admitted to Riyadh Armed Forces Hospital (RAFH).Nothing was found to be contributory from his history, family history or social history except that he was a smoker for 30 years of 20 cigarettes per day one year previously.The physical examination revealed a cachectic male with a temperature of 37.5°C and a pulse of 80 beats per minute. Blood pressure was 120/80 mg/Hg. There was no icterus, lymphadenopathy or clubbing. Heart and lungs were normal. Abdominal examination revealed tenderness in the epigastrium but no mass or organomegaly was felt anywhere.Investigations revealed a hemoglobin of 13.2 g/dl and a total leukocyte count of 5.8x10 9 /L (polymorphs). Erythrocyte sedimentation rate (ESR) was 12 mm during the first hour. The Mantoux test was strongly positive (20 mm x 30 mm) using 1 x 10,000 tuberculin units. Liver function tests showed proteins 83 g/L, albumin 40 gm/L, AG ratio 0.9, total bilirubin 15 μmol/L, alkaline phosphatase 147 u/L, AST 48 u/L (11-55). Chest x-ray was normal. Ultrasound of the abdomen was inconclusive. The pancreas was not visualized.CT scan of the abdomen showed intrahepatic bile duct dilatation and a mass in the head of the pancreas, measuring 5.2 cm x 3.3 cm in size (Figure 1). There were enlarged para-aortic lymph nodes. Upper gastrointestinal tract (GIT) endoscopy showed redness of antral mucosa and deformed rigid pylorus. There was a gross deformity of the bulbar mucosa with edema, ulceration, and contact bleeding. It was difficult to advance the endoscope beyond the proximal part of the bulb. Repeat endoscopy a month later revealed prepyloric erosions and stenosis of the pylorus, because the en...
