2023年 · 第61卷第10期

The patient, a 58-year-old female, was transferred to our hospital by ambulance on February 12, 2023 due to "duodenal mass found for 8 years, melena for 5 days and palpitations for 1 day". The patient found a duodenal mass in a physical examination in another hospital 8 years ago. At that time, the patient had no abdominal pain, abdominal distension, hematemesis, melena, fear of cold and fever, and no yellowing staining of the skin and sclera, which was considered as a benign lesion. At regular follow-up, the patient had no obvious discomfort and was not treated. Before 5 days, there was no obvious trigger for melena, no hematemesis, no dizziness, amaurosis, no abdominal pain, abdominal distension, no fear of cold, fever and other discomfort. After that, there was melena every day, and the amount was not large. 1 day ago, the patient developed palpitations without abdominal pain, fever and other discomfort, so he went to the local hospital for treatment. The results of the local hospital examination showed that hemoglobin was 70 g/L, and the results of abdominal enhanced CT examination showed thickening of the intestinal wall of the descending duodenum for 3/4 weeks, and the enhancement showed isoblood pool enhancement (Figure 1A). Gastroscopy was performed immediately after admission, and the results showed that the mucosa surrounding the descending duodenum was rough and thickened for 3/4 weeks, accompanied by active hemostasis (Figure 1B), and endoscopic hemostasis was difficult. Digital subtraction angiography was also unsuccessful for hemostasis and hemoglobin decreased to 46 g/L. Blood transfusion and fluid rehydration were performed in the local hospital, and they were transferred to our hospital by ambulance. The patient had no previous history of abdominal surgery, denied smoking and drinking, denied hepatitis and tuberculosis, and had 1 son and 1 girl, who was menopausal. Height 158 cm, weight 57 kg, body mass index 22.8 kg/m². Physical examination: clear consciousness, anemic appearance, no yellowing staining of skin and sclera, soft abdomen, no tenderness in abdomen, no rebound pain, negative Murphy sign, no abdominal mass, mobile voiced sound (-), no percussion pain in both kidney areas, and bowel sounds 4 times/min. Emergency room assessment: heart rate 120 beats/min, blood pressure 100/65 mmHg (1 mmHg =0.133 kPa), 20 breaths/min, finger pulse oxygen saturation 100%. Emergency blood routine: white blood cell count 6.11×10⁹/L, red blood cell count 3.19×10¹²/L, hemoglobin 64 g/L; Coagulation function: prothrombin time and activated partial thromboplastin time were normal, fibrinogen 1.75 g/L. Diagnosis: periampullary tumor with massive hemorrhage, hemorrhagic shock (compensatory phase), severe anemia.