No abstract

No abstract

Question: An elderly man with known penetrating Crohn's disease presents for routine colonoscopy to assess disease activity. He was in clinical remission on a combination of infliximab with mercaptopurine. A colonoscopy 6 months ago was aborted owing to poor bowel preparation in the sigmoid and transverse colon although it was noted that he had a possible narrowing in the sigmoid colon (Figure A). The patient was adamant that he took the preparation as requested. A computed tomography (CT) colonography, CT enteroclysis and repeat colonoscopy with extended bowel preparation were performed. The narrowed area was further characterized, appearing to have 2 lumens (Figure B), and 1 lumen was successfully CLINICAL CHALLENGES AND IMAGES IN GI Gastroenterology 2020;159:440-442 traversed with moderate difficulty into what seemed to be ileal mucosa. The CT colonography and CT enteroclysis pictures are shown in Figure C and D, respectively.What is the diagnosis to account for poor bowel preparation? Look on page 442 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI.

No abstract

Question: A 70-year-old woman presented to the emergency department with 3 weeks of melena and 1 recent episode of coffee ground vomiting on a background of intermittent abdominal pain, anorexia and weight loss of 5 kg over the preceding 3 months. Her other medical history was significant for atrial fibrillation treated with apixaban as well as obesity, type 2 diabetes mellitus, and hypertension. She was hemodynamically stable and had mild epigastric tenderness with no features of peritonism. Digital rectal examination confirmed melena. Initial laboratory values showed normocytic anemia with a hemoglobin of 6.0 g/dL, urea of 37.2 mg/dL, creatinine of 1.09 mg/dL, and liver function tests within the normal range. A gastroscopy was performed, which demonstrated a large, solid, incompressible spherical object in the first part of the duodenum with associated semi-circumferential mucosal ulceration but no active bleeding (Figure A, B). There was significant resistance to pushing the object distally and it was too large to extract through the pylorus. A computed Gastroenterology 2020;159:e3-e5 ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI tomography (CT) scan of the abdomen was performed after the gastroscopy, with axial (Figure C) and coronal (Figure D) images shown. What was the diagnosis accounting for the patient's presentation? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.