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April 22, 2019

Image challenge: Rare multiple lesions arising in small and large intestines

What caused multiple lesions in the duodenum, end of the ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid colon and rectum of a patient?

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Gastroenterology clinical image challenge: A 66-year-old woman with dull abdominal pain and watery diarrhea was admitted to our hospital. She presented intermittent nausea, purulent bloody stool (three to four times a day) and dull abdominal pain one year ago. The abdominal pain was more obvious below the umbilicus and relieved after bowel movement. The symptoms got worse six months ago and she went to a local hospital and received mesalamine and hormone enemas. The abdominal pain relieved and purulent bloody stool disappeared after the treatment. However, five months later, the patient began to present abdominal pain and watery diarrhea. The abdominal pain was a still dull ache and relieved after a bowel movement. The diarrhea presented watery stool without mucus, blood or pus. The patient was transferred to our hospital for further investigation and treatment. 

Physical examination revealed tenderness around the umbilicus and in the left lower quadrant. Laboratory studies showed elevated lipase of 98 U/L (normal range, 12–60 U/L), C-reactive protein of 10.00 mg/L (normal range, <6 mg/L), rheumatoid factor of 35.70 IU/ml (normal range, <30 IU/mL), adenosine deaminase of 21 U/L (normal range, 4–18 U/L), and decreased prealbumin of 13.8 mg/dL (normal range, 17.0–40.0 mg/dL), albumin of 35.5 g/L (normal range, 40.0–55.0 g/L), and serum potassium of 3.18 mmol/L (normal range, 3.5–5.3 mmol/L). The blood cell count and tumor markers were unremarkable. Fecal occult blood test was positive.

The patient underwent computed tomography (CT) scanning of the abdomen, an upper endoscopy and a colposcopy. The CT scan revealed mesenteric lymphadenopathy and diffuse intestine wall thickening (Figure). The upper endoscopy and colonoscopy showed a normal stomach and multiple lesions in the duodenum, end of the ileum, cecum, ascending colon, transverse colon, descending colon, sigmoid colon and rectum (Figure). Biopsies obtained during upper endoscopy did not reveal Helicobacter pylori infection. A pathologic examination showed the lesions presented the same characteristics.

What is the diagnosis?

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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