15 | Abdominal Key

History

A 56-year-old lady with iron deficiency anaemia had an upper gastrointestinal endoscopy and colonoscopy, both of which were normal. She has been referred to the specialist outpatient clinic with symptoms of increasing abdominal cramps and vomiting over the past few months.

Physical examination

•Afebrile, pulse 90 bpm, BP 120/80mmHg, SaO₂ 98-100% on RA.

•Hydration status good.

•Examination of the hands reveals no clubbing and normal-appearing palmar creases.

•Head and neck examination is unremarkable.

•Cardiovascular: HS dual, no murmur.

•Her chest is clear on auscultation.

•Abdominal examination reveals a soft, non-tender abdomen, with no definite mass, and bowel sounds are normal.

•Per rectal exam: yellowish stools only.

•No signs of oedema.

Investigations

•CBC:

–WBC 3.9 x 10⁹/L;

–haemoglobin 11g/dL (microcytic hypochromic McHc);

–platelets 263 x 10⁹/L.

•Liver function tests are normal.

•Renal function tests are normal.

•Amylase normal

•Bone profile is normal.

•CRP normal.

•Preliminary abdominal and chest X-rays are normal.

What would you do next?

In view of her iron deficiency anaemia and progressive symptoms, small bowel investigations should be arranged.

The options for small bowel investigations include:

•Capsule endoscopy.

•Deep enteroscopy (push enteroscopy, single-balloon-assisted enteroscopy, double-balloon enteroscopy, etc.).

•Computed tomography enteroclysis or enterography (CTE); or magnetic resonance enteroclysis or enterography (MRE).

This patient has a CT enterography (Figures 15.1 and 15.2).

Please describe what you see

A segment of focal small bowel wall thickening is noted at the proximal to mid ileum with stenosis causing partial obstruction, mesenteric thickening and enlarged mesenteric lymph nodes. This was suspicious of infiltrative disease.

What is your differential diagnosis?

•Neoplasm:

–adenocarcinoma;

–lymphoma;

–carcinoid tumour.

•Infection:

–tuberculosis.

How would you proceed?

An histological specimen is needed for definitive diagnosis. A double-balloon enteroscopy is performed (Figure 15.3).

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