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Image challenge: Bowel ultrasound — no longer a cinderella of bowel imaging

What caused a 67-year-old woman, whose laboratory tests showed microcytic anemia, increased acute phase proteins, and malabsorption, to present with a low-grade fever, diarrhea and a 20-kg weight loss?

Gastroenterology clinical image challenge: A 67-year-old woman presented with a year-long history of general malaise, low-grade fever, diarrhea and a 20-kg weight loss. She had a history of hypertension and depressive disorder. In the previous four years, she had undergone several rheumatologic examinations for polyarthritis and, having been diagnosed with seronegative rheumatoid arthritis, she had been treated with steroids, methotrexate and etanercept, with little benefit.

Recent laboratory tests showed: hemoglobin, 8.3 g/dL; mean corpuscular volume, 70 fL; erythrocyte sedimentation rate, 78; and C-reactive protein, 6.4 mg/dL. To evaluate the microcytic anemia and the diarrhea, endoscopic investigations had been performed a few months earlier. Esophagogastroduodenoscopy showed villous atrophy at the level of DII; histology was compatible with intramucosal xanthoma. There were no pathologic findings at colonoscopy. The situation had not been further investigated.

At presentation, the physical examination revealed lower limb edema, skin and mucosal pallor, and a body mass index of 17.4 kg/m2. Laboratory tests showed microcytic anemia (hemoglobin, 10.0 g/dL; mean corpuscular volume, 74 fL), increased acute phase proteins (erythrocyte sedimentation rate, 59; C-reactive protein, 8.53 mg/dL) and malabsorption (albumin, 2.5 g/dL; multiple electrolytes deficiencies including iron, vitamin A and vitamin D deficiency).

Abdominal ultrasound examination revealed three small lymph nodes in the periaortic region (maximum diameter, 10 mm), marked mesenteric and ileal wall thickening, mild jejunal wall thickening, an increased number of connivent valves, and a mild amount of peri-intestinal fluid effusion (Figure).

What is the likely diagnosis and the appropriate treatment?

To find out the diagnosis, read the full case in Gastroenterology or download our Clinical Image Challenge app through AGA App Central, which features new cases each week. Sort and filter by organ, most popular or favorites. AGA App Central is available in both the Apple App Store and Google Play.

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