Diagnostic Dilemma

Prepared by Lisa Lee, MD, and Judy Yee, MD

In those issues in which our regular Case of the Month does notappear, The Green Journal will present a Diagnostic Dilem-ma—an electrocardiogram and/or radiograph with a brief casehistory—for our readers to solve. The correct answer appearson p. 511 of this issue.

If you would like to contribute a Diagnostic Dilemma, pleasesubmit a high-quality copy of the EKG or radiograph with abrief synopsis (,250 words) of the case to The American Journalof Medicine’s editorial office. Am J Med. 2000;108:503. q2000by Excerpta Medica, Inc.

A77-year-old man presented after 2 days of nauseaand copious bilious vomiting. One month earlier,the patient had 1 to 2 weeks of post-prandial vom-

iting, which subsequently resolved. The patient had a his-tory of a cerebral infarct and was taking aspirin. In theemergency department, an NG tube aspirate yielded 1600cc of coffee ground material with relief of nausea. Thepatient was afebrile. His abdomen was not tender; bowelsounds were normal. Laboratory evaluation revealed no

leukocytosis, normal liver function, and normal coagula-tion factors.

At endoscopy, marked narrowing of the pyloric chan-nel was seen with erosion and granularity, but withoutfrank ulceration. The cause of the gastric outlet obstruc-tion was unclear, and narrowing precluded further endo-scopic visualization.

Computerized tomographic (CT) scan of the abdomenwas performed as shown below:

Figure.

q2000 by Excerpta Medica, Inc. 0002-9343/00/$–see front matter 503All rights reserved. PII S0002-9343(00)00358-2