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Blood and guts
  1. Robin John Dart1,2,
  2. Mallika Sekhar3,
  3. Katie Planche4,
  4. Martyn Caplin2,
  5. Charles Murray2
  1. 1Peter Gorer Department of Immunobiology, King's College London, London, UK
  2. 2Gastroenterology and Hepatobiliary Medicine, Royal Free London NHS Foundation Trust, London, UK
  3. 3Haematology, Royal Free Hospital, London, UK
  4. 4Radiology, Royal Free Hospital, London, UK
  1. Correspondence to Dr Robin John Dart, Peter Gorer Department of Immunobiology, King's College London, London, London, UK; robin.dart{at}

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A 30-year-old woman with long-standing irritable bowel syndrome presented to the emergency department with syncope, on a background of 3 weeks of bloody diarrhoea and 6 kg weight loss. She did not smoke, took only the combined oral contraceptive and reported no recent travel.

Laboratory tests revealed a macrocytic anaemia: Hb 48 g/L mean corpuscular volume 100.8 fL and reticulocytes 115.2 109 /L. Liver function was deranged: bilirubin 31 μmol/L, alanine transaminase 115 U/L aspartate transaminase 150 U/L albumin 23 g/L, international normalized ratio 1.3. C reactive protein 29, and creatine was 90 µmol/L and urea 2.7 mmol/L. Haematinics were normal. She was transfused 2 units of blood, but despite blood transfusion did not significantly increment the Hb, with ongoing bloody diarrhoea. Serum haptoglobin was <0.1 g/L, lactate dehydrogenase 549 and bilirubin 24 µmol/L; direct antiglobulin test (DAT) …

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  • Contributors RJD wrote the manuscript. KP selected and annotated the images. All authors edited and critically appraised the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.