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A 73-year-old man with a history of heart failure and hypertension presented with a several-week history of generalised weakness, anorexia, 5 kg weight loss, intermittent small volume hematochezia and right upper quadrant abdominal pain. He denied fever, chills, dysphagia, nausea, vomiting, diarrhoea and constipation. He had no previous endoscopy or colorectal cancer screening.
His admission vital signs were normal. He was anaemic (haemoglobin 8.6 g/dL reference 12–18 g/dL), with mean corpuscular volume 83 (81–100 fL/cell), ferritin 321.9 (11–336 ng/mL), alkaline phosphatase 174 (38–127 IU/L), albumin 2.4 (3.5–4.9 g/dL), total bilirubin 0.8 (0.2–1.2 mg/dL) and aspartate aminotransferase/alanine aminotransferase 28/21 (10–40 U/L, 7–56 U/L). Serological tests for hepatitis and HIV were negative. RPR was negative 1 month previously. CT imaging with intravenous contrast (figure 1) revealed six target-like liver lesions (0.7 to 1 cm) with peripheral arterial enhancement and several enlarged coeliac lymph nodes (largest 0.8 cm). Due to anaemia/hematochezia, upper and lower endoscopy were performed. His oesophagogastroduodenoscopy showed …
Contributors DS performed background research and assisted in drafting and reviewing the manuscript, as well as in drafting reviewer responses. DS submitted the finalised work. H-sK performed background research and assisted in drafting and reviewing the manuscript. CGT assisted in drafting and reviewing the manuscript, as well as drafting reviewer responses. EB provided discussion of pathology and assisted in drafting and reviewing the manuscript. NK assisted in drafting and reviewing the manuscript. RH assisted in drafting and reviewing the manuscript, as well as in drafting reviewer responses. RH assisted in submitting the finalised work.
Funding This material is based upon work supported (or supported in part) by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, and the Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413).
Disclaimer The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.
Competing interests None declared.
Patient consent for publication Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.