{'fraction_non_alphanumeric': 0.027427078798432737, 'fraction_numerical': 0.00914235959947758, 'mean_word_length': 4.702233250620347, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
CONGENITAL DUODENAL DIAPHRAGM

An 18-year-old girl with spina bifida was referred from general practice for investigation of melena and chronic anemia. She had been feeling lethargic and nauseated for 5 days and noticed her stool had turned dark black two days earlier.There was no diarrhea, abdominal pain or vomiting and she denied any previous history of bleeding per rectum, changes in bowel habit, loss of weight,early satiety or anorexia.Her hemoglobin measured at her general practice was 5.8 g/dL. She had had an esophagogastroduodenoscopy (EGD) 14 months prior for investigation of anemia but no cause was found. Her history included spina bifida and congenital ventricular septal defect that was repaired in the first 4 months. However, apart from these she had enjoyed good health and had no vomiting or feeding issues during her childhood. She was not on any regular medications, including non-steroidal anti-inflammatory drugs (NSAID). She was a non-smoker and a non-drinker. Physical examination revealed a pale, anxious girl with gross scoliosis of the back. She was afebrile, had a pulse rate of 125 b.p.m. and a blood pressure of 120/70 mmHg. Abdomen was soft with no tenderness or palpable mass. Digital rectal examination was performed, which revealed black tarry stool. Chest X-ray did not reveal any significant findings. Meckel’s scan was performed but there was no evidence of ectopic gastric mucosa. A repeat EGD was undertaken, which revealed a large mobile polypoid lesion in the duodenum prolapsing through the pylorus (Fig. 1). There appeared to be an active bleeding ulcer on the mucosa of the duodenum (Fig. 2). The scope could not be passed into D3 and there was no obvious opening. The patient subsequently underwent an exploratory laparotomy. There was no visible dilatation of the duodenum. A longitudinal duodenotomy along the anterior second part was performed. There was blood throughout the gastrointestinal tract.There was a duodenal diaphragm at the junction of the second and third parts of the duodenum. The diaphragm had windsock morphology and had an eccentric aperture of approximately 1 cm (Fig. 3). There was an ulcer on the inferior surface of the diaphragm with blood clot still adherent, possibly arising from mechanical stimulation of the mucosa.