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(a) An abdominal computed tomographic scan showing a tumor in the medial wall of the second portion of the duodenum and the neighboring part of the pancreas. Intravenous contrast injection showed markedly increased vascularity in this region. (b) Selective angiography: Increased blood flow at the level of the gastroduodenal artery and first jejunal branches of the superior mesenteric artery is observed, with early venous outflow to the portal vein, consistent with the diagnosis of arteriovenous malformation.
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Contrast computed tomographic (CT) scan demonstrated a 2-cm tumor in the wall of the second portion of the duodenum; intravenous contrast showed markedly increased vascularization in this region (Fig. 1a). Selective pancreaticoduodenal arteriography showed a blush in the papillary region with rapid venous filling consistent with the diagnosis of arteriovenous malformation (Fig. 1b).
(a) Endoscopic duodenojejunal biopsy: At the level of the submucosa, a conglomerate of thick-walled hamartomatous vessels is clearly observed. (b) Operative specimen of the ampullary region: Several tortuous vessels, with arterial and venous patterns, suggestive of arteriovenous malformation are seen in the submucosa.
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At laparotomy, full thickness wall biopsies showed dysplastic vessels in the mucosa and submucosa (Fig. 2a). These findings confirmed the diagnosis of arteriovenous malformation of the duodenum (Fig. 2b).
Schematic diagram of pancreaticoduodenectomy: (A and B) The entire duodenum was removed along with the head of the pancreas; (C) a pylorus-preserving pancreaticoduodenectomy, with biliary and pancreatic diversion into a Roux-en-Y jejunal loop was performed.
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A pyloric-preserving cephalic pancreaticoduodenectomy with biliary and pancreatic diversion into a Roux-en-Y jejunal loop was performed (Fig. 3).