What is the best course of treatment for a 65-year-old female with chronic kidney disease (CKD) on dialysis, presenting with severe abdominal pain, bilious vomiting, and diarrhea, and found to have a thickened duodenum with ulceroproliferative lesions on computed tomography (CT) scan and upper gastrointestinal (GI) endoscopy?

Urgent Biopsy Results and Malignancy Workup Required

The immediate priority is obtaining the histopathology results from the D2 biopsy to determine if this ulceroproliferative lesion represents malignancy (duodenal adenocarcinoma or lymphoma), which is the most critical concern given the endoscopic appearance and clinical presentation. 1

Critical Next Steps

Immediate Management (Within 24-48 Hours)

• Expedite pathology results from the D2 biopsy specimens, specifically requesting immunohistochemistry if initial H&E is inconclusive, as ulceroproliferative lesions in the duodenum carry high suspicion for malignancy in this age group 1

• Maintain NPO status or clear liquids only given the risk of perforation with ulceroproliferative lesions involving the thin duodenal wall, which is highly susceptible to perforation 1

• Initiate high-dose proton pump inhibitor therapy (twice daily IV dosing) to reduce acid-related injury to the ulcerated area, though this must be renally adjusted for dialysis patients 1

• Monitor hemoglobin closely (daily CBC) as duodenal lesions carry significant bleeding risk, particularly problematic in dialysis patients with uremic platelet dysfunction 2, 3

Differential Diagnosis Considerations

Malignancy (Primary Concern):

• Duodenal adenocarcinoma presents as ulceroproliferative lesions in D2, particularly with medial to lateral wall involvement 1
• Lymphoma can present similarly with thickened, ulcerated mucosa 1

Uremia-Related Pathology:

• Uremic duodenitis/gastroduodenopathy occurs in dialysis patients and can cause erosive changes, though typically less focal than described here 4, 2, 3
• The polypoid lesions in D1 combined with ulceroproliferative changes in D2 make isolated uremic pathology less likely 2

Infectious Etiologies:

• The esophageal whitish plaques suggest candidiasis, raising concern for immunocompromised state that could predispose to CMV duodenitis or other opportunistic infections 2
• Request CMV immunostaining and viral cultures on biopsy specimens 2

Management Algorithm Based on Biopsy Results

If Malignancy Confirmed:

Staging workup immediately:

• CT chest/abdomen/pelvis with IV contrast (if residual renal function permits, otherwise non-contrast)
• Tumor markers (CEA, CA 19-9)
• Multidisciplinary tumor board discussion involving surgical oncology, medical oncology, and nephrology 1

Surgical evaluation:

• For localized duodenal adenocarcinoma, pancreaticoduodenectomy (Whipple procedure) may be required, though operative risk is substantially elevated in dialysis patients 1
• Palliative considerations must be discussed given CKD on dialysis and surgical risks 1

If Severe Uremic Duodenopathy:

• Intensify dialysis regimen to improve uremic control, as uremia-associated GI lesions can improve with adequate dialysis 4, 3
• Consider daily or extended dialysis sessions temporarily 4
• Nutritional support via TPN if oral intake remains contraindicated 3

If Infectious (CMV, HSV, Candida):

• Initiate pathogen-specific therapy immediately:
  • Ganciclovir for CMV (renally dosed)
  • Fluconazole for candidiasis (already suggested by esophageal findings) 2
• Evaluate for underlying immunosuppression causes 2

Critical Monitoring Parameters

Daily assessments required:

• Hemoglobin/hematocrit for bleeding surveillance 2, 3
• Vital signs for hemodynamic instability 1
• Abdominal examination for peritoneal signs suggesting perforation 1
• Stool character and frequency 5, 2

Dialysis considerations:

• Avoid heparin anticoagulation during dialysis sessions until bleeding risk clarified 1, 2
• Schedule dialysis to optimize timing if surgical intervention needed 1

Common Pitfalls to Avoid

• Do not delay biopsy results - expedite with pathology department as management hinges entirely on histologic diagnosis 1

• Do not assume uremic gastropathy explains focal ulceroproliferative lesions; uremic changes are typically diffuse and less destructive 2, 3

• Do not restart anticoagulation (if patient was on any) until bleeding risk fully assessed and lesion characterized 1

• Do not perform repeat endoscopy for surveillance until pathology reviewed, as manipulation risks perforation of the thin duodenal wall 1

Prognosis Considerations

The combination of CKD on dialysis with a potentially malignant duodenal lesion carries grave implications for both morbidity and mortality. If malignancy is confirmed, surgical options are limited by operative risk, and systemic chemotherapy dosing is complicated by renal failure 1, 3. Quality of life considerations must be central to all treatment decisions, with early palliative care involvement if advanced malignancy is diagnosed 1.