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Unexplained weight loss and a palpable abdominal mass in a middle aged woman
  1. N D Hawkes,
  2. G A O Thomas
  1. Department of Gastroenterology, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, UK
  1. Dr Thomas

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Answers on p 348.

A 52 year old woman presented to the gastroenterology department with a six month history of unexplained weight loss of 2 stone (12.7 kg). She had experienced intermittent abdominal cramp-like pains but was otherwise well. In particular, there had been no alteration to her bowel habit and no rectal bleeding. Her appetite had been normal. She denied any systemic symptoms such as fatigue or night sweats. She was born in the UK, and had not travelled abroad, however her father had originated from the Yemen. Her brother had suffered bony tuberculosis 30 years previously but she had not had previous documented infection.

Three months before review she had been seen in another department for unexplained weight loss. Routine blood tests and a chest radiograph were normal. A barium meal examination showed an 8 cm, non-distensible narrowing in the upper oesophagus but a follow up endoscopy was normal. Because of ongoing weight loss she was referred to the gastroenterology department.

Apart from a thin appearance (weight 40.4 kg), general, cardiovascular, and respiratory examinations were normal. On abdominal examination a firm, non-tender, fixed mass was palpable in the right iliac fossa. Rectal examination and a rigid sigmoidoscopy were normal.

Initial investigations revealed an iron deficiency anaemia (haemoglobin concentration 104 g/l, mean corpuscular volume 79.2 fl, mean corpuscular haemoglobin 24.9 pg, ferritin 12.0 μg/l), total leucocyte count 6.79 × 109/l, platelets 413 × 109/l, serum albumin 34 g/l, erythrocyte sedimentation rate 60 mm/hour, and C reactive protein 27 mg/l. Urea and electrolytes, creatinine, glucose, liver and thyroid function tests, serum B12 and folate screen, a chest radiograph, and an electrocardiogram were normal. Abdominal ultrasound demonstrated a 2 cm ill defined mass in the right iliac fossa.

To further investigate her iron deficiency anaemia, weight loss, and right iliac fossa mass a small bowel follow-through and barium enema (figs 1 and 2) were performed.

Figure 1

Double contrast barium enema study.

Figure 2

Detailed view of the diseased area seen in fig 1.

Questions

(1)
What does the barium enema study (figs 1 and 2) show?
(2)
What is the differential diagnosis and what test should be performed to confirm the diagnosis?
(3)
What treatment would you initiate?

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