Clinicopathological case: Weight loss, diarrea, small bowel changes.

A 33-year-old woman previously healthy started three months before consulting with asthenia, weight loss, abdominal pain and mild diarrea without fever. Physical examination at the first visit showed a patient with the impression of an important disease with bilateral leg edema. No vomiting. Blood test showed a sideropenic anemia, hypoalbuminemia. Kidney and thyroid function were normal. Gastroscopy and colonoscopy normal.

D-xylosa test and fecal culture were normal. Clostridium difficile negative. Red congo negative. No steatorrhea.

Gastric and colonic biopsy: inflamatory; no parasites or bacterias.

She suffered a clinical deterioration without a response to wide spectrum antibiotic.

You can access to the first part of the presentation in slideshare here: .http://es.slideshare.net/lorenzo-alonso/autopsia2. The final answer will be provided after 11.00 hours AM, USA East time, the 22th march (16 hours Madrid, Spain).

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We have followed the concept of Illness script developed in the article: Educational Strategies to Promote Clinical Diagnostic Reasoning. Bowen JL. N Engl J Med 2006; 355:2217-2225November 23, 2006DOI: 10.1056/NEJMra054782

Illness script are PERSONAL, every doctor can build their own but all of them must followed some principles exposed here, taken from the course “Clinical Problem Solving”, UCSF, Dr. Catherine R. Lucey.

FINAL DIAGNOSIS: SMALL BOWEL NON-HODGKIN LYMPHOMA

                                                                              Small Bowel biopsy: diffuse infiltration lymphoid cells.

You can see the radiographical and biological comparison.

UPTODATE: CAT scan in small bowel lymphoma: “of particular concern are bowel wall segments with homogeneous thickening greater than 2 cm, with a normal enlarged lumen”.

There are patches of white aspect around the small bowel wall.

DIFFERENTIAL DIAGNOSIS (ILLNESS SCRIPT): MALABSORPTION/DIARRHEA

Another diffrentials that could be included: celiachia, Zollinger-Ellison syndrome.

Author: Lorenzo Alonso,MD. Acknowledgments: Pathology Dpt. Internal Medicine Dpt.