2015-06-16 15:56:57 UTC

46-Year-Old Male with Coagulopathy and Lower Extremity Edema

June 17, 2015

The June Gastro image challenge features a patient with no remarkable medical history and overall good health until two years before admission.

Question: A 46-year-old white male prisoner of 16 years, presented with coagulopathy and lower extremity edema. He had no remarkable medical history, reporting overall good health until two years before admission. At that time, he had experienced gradual onset of loose stools, which have persisted intermittently since. He felt this to be worse with certain meals, particularly those high in carbohydrates. He reported an associated, unintentional weight loss of 30 pounds in the previous year. He denied any melena, hematochezia, hematemesis, abdominal pain, skin rashes, bleeding events, easy bruising or other complaints throughout the course of his illness. There was no family history of bleeding diatheses. At the time of referral, he was on oral iron supplementation, which he stated was for anemia, a cause of which had not been identified.

His first visit encounter with our institution was through the hematology telemedicine clinic one month before hospital admission, at which time repeat coagulation laboratory tests were recommended to his prison unit. When these laboratory tests were confirmatory, he was admitted to the hospital for additional workup. His physical examination revealed mild, nonpitting, bilateral lower extremity edema, but was otherwise entirely normal. Additional laboratory tests, including d-dimer, fibrinogen, fibrin degradation products, lupus anticoagulant, factor inhibitor assay, hepatitis serologies, human immunodeficiency virus screening, vitamin B12, folate and thyroid function tests were all normal. A malabsorptive process was suspected and abdominopelvic CT with intravenous contrast was obtained, showing mildly prominent and fluid-filled loops of small bowel with hyperemic mucosa. The critical finding of jejunoileal fold pattern reversal was also seen (Figures A through C).

Answer: To find out the diagnosis and to read the full description, see the article in Gastroenterology.

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