2016-09-22 14:24:28 UTC

What's the Cause of This Patient's Gastrointestinal Ulcers?

Sept. 22, 2016

The patient was treated 15 years ago with interferon alpha for infection with HCV genotype 1, but the treatment failed to eradicate the virus.

Question: A 48-year-old man was referred to the hospital for further evaluation and treatment of recurrent abdominal pain and hematochezia. He was treated 15 years ago with interferon alpha for infection with HCV genotype 1; however, the treatment failed to eradicate the virus. He also had renal dysfunction caused by membranoproliferative glomerulonephritis five years ago. Since then, he has been treated with prednisolone and cyclosporine. Six months before referral to the current hospital, he visited a neighboring hospital with complaints of leg purpura and abdominal pain.

Thereafter, the HCV infection was treated with daclatasvir and asunaprevir. However, his abdominal pain worsened and hematochezia appeared before referral to the current hospital. Physical examination revealed left upper abdominal pain with tenderness, leg edema and purpura, and a tattoo on his back, but no signs of arthritis or peripheral neuropathy.

Esophagogastroduodenoscopy demonstrated irregular ulcers accompanied by circumferential mucosal erythema in the second portion of the duodenum (Figure B). A colonoscopy revealed scattered erosions in the terminal ileum and multiple scarred ulcers throughout the colon. Capsule endoscopy and balloon-assisted endoscopy revealed multiple active and scarred ulcers in the duodenum and small intestine.

What's the diagnosis?: Visit Gastroenterology online to find out the cause of patient's ulcers or view the image challenge on the AGA Clinical Image Challenge app, available on AGA App Central. The app, which features new cases each week, allows you to sort and filter by organ, most popular or favorites. AGA App Central is available in both the Apple App Store and Google Play.

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