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A 42 year old unemployed male was referred to the gastroenterology department for investigation of constant severe abdominal pain and profound weight loss (45 kg over an eight month period). Further questioning revealed intermittent diarrhoea, steatorrhoea, and rectal bleeding. He was a smoker of 60 cigarettes per day but denied alcohol excess.
Examination revealed a cachectic man but no specific positive findings were revealed on systems examination.
Endoscopy with distal duodenal biopsy, pancrealauryl test, and plain computed tomography of the abdomen were all normal. Colonoscopy revealed normal colonic mucosa.
A view of the terminal ileum is shown in fig 1; describe the appearance and the most likely diagnosis(es).
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