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A 45‐year‐old Italian man, living in Italy, was admitted to our clinic with a 6‐month history of chronic diarrhoea (soft stool, 3–4 times/day), iron‐deficiency anaemia, recurrent abdominal pain, weight loss (10 kg over 6 months) and weakness. Examination was normal apart from moderate pallor and a soft but diffusely tender abdomen. He was not febrile: there was no pathological sign apart from increased bowel sounds. Other investigations showed haemoglobin 10.8 g/dl, mean corpuscular volume 72 fl, full blood count normal with relative hypereosinophilia (8.5%), platelets 230×109/l, erythrocyte sedimentation rate 60 mm/h, C reactive protein <1.0 mg/l, normal renal and hepatic biochemistry, albumin (30 g/l), serum iron 10 μg/l, total iron‐binding capacity 330 μg/dl (normal: 240–480 μg/dl) and ferritin 7 ng/ml (20–200 ng/ml).
Parasitological stool examination was non‐diagnostic, with normal stool pH. Coproparasitological study was negative; stool specimens for faecal leucocytes, bacterial culture, ova and parasites were all negative and pH was normal. Occult blood was found repeatedly in the stool.
Routine biochemical examinations including thyroid function test, protein electrophoresis and serum immunoglobulin levels were all normal, and antigliadin antibodies (IgG, IgA) were negative. HIV‐1 and HIV‐2 were also negative.
Chest x ray and barium follow‐through were all normal. Upper endoscopy with gastric and duodenal mucosal biopsies was unremarkable. Colonoscopy was difficult and performed only up to the mid‐sigmoid colon because of poor luminal distension due to perivisceral phenomena resulting from previous diverticulitis. Double‐contrast barium enema was therefore used to evaluate the colon, but did not yield significant findings. Abdominal ultrasound showed widespread abnormalities with ileal loops and moderately dilated, fluid-filled jejunal loops with oedematous wall thickening (fig 11).). A few small (12mm) peri-intestinal lymph nodes were detected. Localised peritoneal fluid was present in the right iliac fossa. Despite extensive investigations the diagnosis remained uncertain.
How would you explain the clinical context and sonographic findings and what further diagnostic procedures you would like to perform?
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Competing interests: None.