Contributed by Xiaoyan Wang, MD, PhD, Wen-Wei Chung, MD, PhD, Larry Nichols, MD, and Jeannette Dunn, MD
Published on line in July 2001
This 75-year-old female with cryptogenic cirrhosis, portal hypertension, hypersplenism, pancytopenia, hypothyroidism and type II diabetes mellitus developed hepatic encephalopathy requiring chronic lactulose and Neomycin therapy. She was discovered to have vitamin B12 deficiency, which was treated with intramuscular injections of B12. Six months later, she presented with an abrupt decrease in her hemoglobin to 7 g/dL and evidence of iron deficiency with an iron saturation of 4%. She denied melena, hematochezia, nausea, vomiting or diarrhea. She was transfused. Upper gastrointestinal endoscopy showed esophageal varices, portal hypertensive gastropathy and a 1.2 cm submucosal mass in the duodenum, which was biopsied.
The specimen consisted of two fragments of firm tan tissue measuring 0.1 and 0.3 cm in maximum dimension.
The biopsies demonstrated small intestinal mucosa with normal villous structures (Images 1 and 2). There were mildly increased numbers of lymphocytes and plasma cells in the lamina propria. Several flattened cells were present on the surface of the epithelium (Images 3 and 4). These cells were pear shaped with paired nuclei (Images 3 and 4).