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A 62-year-old man with a history of chronic hepatitis B cirrhosis presented with deteriorating liver function. The serum α fetoprotein (AFP) level was 253 kU/l (normal upper limit <7 kU/l) and three lesions were found on CT of the liver; one of 4.5 cm diameter and two <1 cm. He underwent an orthotopic liver transplant, and hepatocellular carcinoma (HCC) was confirmed on histological examination of the explanted liver. The patient recovered uneventfully with good graft function.
At 2 months after surgery, the AFP level had increased to 1530 kU/l but no new lesions suggestive of HCC were demonstrated on CT of the liver and abdomen. The patient remained well with good graft function, but serial AFP measurements remained elevated (between 31 and 2476 kU/l). At 16 months after transplantation, the patient was noted to be persistently anaemic (serum haemoglobin 9.5 g/dl). Oesophagogastroduodenoscopy and colonoscopy were normal. Haemoglobin continued to fall to 5.9 g/dl with serum ferritin 3 μg/l.
A video capsule endoscopy was performed; fig 1 shows an image obtained from a lesion identified within the jejunum. Figure 2 shows the histology obtained from the biopsy specimen at subsequent enteroscopy.
What is the unifying diagnosis?
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This article has been adapted from Joshi Deepak, Rela Mohammed, Rizzi Paolo, Heneghan Michael, O’Grady John, Portmann Bernard, O’Donohue John. Iron-deficiency anaemia Gut 2007;56:1046
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