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A young woman with intractable diarrhoea

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A 28 year old saleswoman reported loose motions of three years' duration. She was symptomatic with recurrent copious watery loose motions five to six times a day, which had progressively worsened. Symptomatic treatment with antimotility agents had provided poor relief.

Moderate hypertension had been diagnosed seven years before, which was controlled with enalapril 5 mg/day. Over a period of four years her blood pressure settled to normal levels. Enalapril was discontinued three years ago and her blood pressure remained normal. Her father had died suddenly of hypertension and “abdominal tumour”.

On clinical examination her blood pressure was 130/76 mm Hg with no postural fall. The rest of the general and systemic examination was normal. Her packed cell volume, complete blood counts, peripheral blood smear, serum potassium, sodium, calcium, phosphate, albumin, glucose, serum creatinine, thyroid profile, stool microscopy and culture, fecal fat excretion, D-xylose absorption test, upper gastrointestinal endoscopy, colonoscopy, small intestinal biopsy, small bowel barium follow through, abdominal and chest radiographs were normal. HIV antibodies were negative by enzyme linked immunosorbent assay. The serum and urine drug, toxicology, and laxative screen were negative. The serum concentrations of serotonin, gastrin, somatostatin, vasoactive intestinal peptide, and calcitonin were normal. Concentrations of urinary 5-hydroxyindole acetic acid and plasma nore-pinephrine and epinephrine were normal. The plasma dopamine concentration was 0.94 ng/ml (normal <0.03 ng/ml), and urine dopamine excretion was 12 000 μg/day (normal 50–480 μg/day). The urinary homovanillic acid was 13 mg/day (normal <7 mg/day). Urinary adrenaline, noradrenaline, metanephrine, and normetanephrine concentrations were normal. A contrast enhanced computed tomogram of the abdomen was done (fig1).

Figure 1

Contrast enhanced computed tomogram of abdomen.

Questions

(1)
What is the diagnosis?
(2)
What is the cause of diarrhoea?
(3)
What is the cause for remission of her hypertension?

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