Gastroenterology clinical image challenge: A 25-year-old woman was referred for evaluation of possible chronic intestinal pseudo-obstruction (CIPO). She reported a 13-year history of self-limited episodes of generalized abdominal pain, nausea, emesis, inability to tolerate oral intake and constipation. In the preceding two years, four discrete episodes had required inpatient admission for conservative management of small intestinal obstruction. During these episodes, she would lose 10–20 lb. Each time, her symptoms resolved over a one-week period. She was asymptomatic between episodes and would regain her weight. She denied any other gastrointestinal or systemic symptoms and personal or family history of gastrointestinal disorders.
Prior evaluation demonstrated no significant abnormalities in her complete blood counts, comprehensive metabolic panels and thyroid function tests. Two esophagogastroduodenoscopies and two colonoscopies with random biopsies of the stomach, duodenum and colon were unremarkable. A number of abdominal computed tomography scans performed during the acute episodes demonstrated small bowel dilation. Eight months prior, she underwent an exploratory laparoscopy and the small bowel was run laparoscopically. Three months later, during a subsequent laparoscopy, a second negative small bowel run was performed.
At presentation, she was in no distress and physical examination revealed a soft, flat, and nontender abdomen, without hepatosplenomegaly or masses. Laboratory studies (reference range in parenthesis) revealed hemoglobin 13.7 g/dL (12.0–15.5), potassium 5.2 mmol/L (3.6–5.2), calcium 9.6 mg/dL (8.9–10.1), alkaline phosphatase 39 U/L (37-98), aspartate aminotransferase 39 U/L (37–98), alanine aminotransferase 15 U/L (7–45), total bilirubin 0.7 mg/dL (≤ 1.2), creatinine 1 mg/dL (0.6–1.1), thyroid-stimulating hormone 1.9 mIU/L (0.3–4.2) and C-reactive protein <3 mg/L (≤ 8).
What is the most likely etiology for the patient’s abdominal complaints?
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