LAURA W. LAMPS
University of Arkansas for Medical Sciences
Little Rock, AR
A 35-year-old female presented to surgery clinic following two episodes of severe upper
gastrointestinal bleeding. She denied significant weight loss, nausea, vomiting, or epigastric pain.
Past medical history was significant for previous cholecystectomy, tonsillectomy, appendectomy, and
two unremarkable pregnancies. Initial laboratory evaluation revealed mild anemia but no other
abnormalities. Endoscopy was performed, and a 4 cm mass was found in the gastric cardia; biopsy
revealed poorly differentiated carcinoma. The patient was scheduled for gastrectomy. On the day
before surgery, a routine pre-operative pregnancy test was positive. Subsequent serum ß-HCG testing
was obtained, yielding a ß-HCG level of 3,473 mIu/ml, consistent with a 4-week gestation. The patient
denied pregnancy, as she was compliant on her oral contraceptive pills and had no physical signs of
pregnancy. In addition, transvaginal pelvic ultrasound showed no intra-uterine gestation, nor
evidence of ectopic pregnancy or adnexal masses. Serial ß-HCG measurements over the next week did not
change significantly. The patient ultimately underwent surgery and an H&E section of the subtotal
gastrectomy specimen is submitted for review.
JOEL K. GREENSON
University of Michigan Medical School
Ann Arbor, MI
The patient is a 38-year-old female who underwent a partial mastectomy for invasive ductal carcinoma
with 1 of 4 lymph nodes positive for metastatic disease. A CT scan of the chest showed esophageal
thickening suggestive of a mass. Upper endoscopy revealed a submucosal mass in the lower esophagus
from 33 to 37 cm. There was a central ulcer with umbilication. Multiple biopsies were obtained and
the patient ultimately underwent a transhiatal esophagectomy. The slides and photomicrographs are
from the resection specimen.
CHRISTINE M. HOBBS
Armed Forces Institute of Pathology
A 28-year-old female presented with occasional streaks of bright red blood in her stools. On further
questioning the patient gave the history of frequent episodes of constipation. Proctosigmoidoscopic
examination revealed two shallow ulcers in a nodular area of the anterior wall of the rectum at 8 cm.
This area was biopsied and interpreted as adenocarcinoma arising from a tubular adenoma. A resection
was subsequently performed and representative sections of this lesion are submitted for your review.
SHARI L. TAYLOR
GI Pathology Partners, PC
A 72-year-old woman presented with nausea, vomiting, and a 25-lb weight loss over a several week
period. On physical examination, there was mild epigastric tenderness to palpation. A CT scan of the
abdomen revealed a large mass at the root of the mesentery. An exploratory laparotomy was performed
and several mesenteric biopsies obtained.
SUSAN C. ABRAHAM
A 68-year-old man was admitted to an outside hospital because of epigastric pain, melena, and
hematemesis that required multiple transfusions. His past medical history was significant for
cardiomyopathy that had required pacemaker insertion, and he was receiving aspirin and Coumadin at the
time of his gastrointestinal bleed. Upper endoscopic examination during that admission revealed a
large gastric ulcer located in the posterior aspect of the antrum. The patient was told that he was
negative for H. pylori (although it is not clear from the medical record how that determination was
made). He was started on Prevacid 30-mg b.i.d. Because of persistent mild epigastric pain as an
outpatient, repeat upper endoscopy was performed 9 months later and showed a persistent posterior
antral ulcer that measured 5 cm. He eventually underwent hemigastrectomy with vagotomy and a Billroth
II gastroduodenal anastomosis. The slide shown includes both antral ulcer and adjoining viable antral
mucosa and wall. The duodenum (to be shown later) had similar findings but lacked ulcers.