A 73 year-old woman was admitted to the Osler Medical Service for evaluation of abdominal pain.

The patient is a 73-year-old woman with a history of diabetes mellitus Type II, hypertension and alcohol use who presents to JHH with severe abdominal pain. She was recently discharged from an outside hospital after an 11-day stay during which her abdominal pain was being worked up. She left the hospital before the evaluation was complete, with a preliminary diagnosis of Crohn's disease.

The patient reports that she has 10/10 abdominal pain localized roughly to the left side, that is colicky in nature and radiates to the back. She reports her pain is not related to food, breathing or movement, although it is difficult for her to sit still. She has been having abdominal pain for the past 6 months and has a history of non-bloody diarrhea, about 5 stools/day, for the past 5 years. She reports a weight loss of 10 lbs in the past 2 months, with decreased appetite. She vomited once the day of admission. There is no history of hematemesis, melena, or bloody stools. She denies chest pain, shortness of breath, cough, headache, dizziness, or urinary symptoms. She has had no rashes or easy bruising or bleeding, but does report that her face "gets red and hot" when she is brushing her teeth. She has a history of alcohol use, but has never had an episode of acute pancreatitis.

The patient has a history of Type II diabetes mellitus and hypertension.

None

Mother lived to 93, father died when patient was young (unknown cause), sister died of unknown type of cancer. No history of inflammatory bowel disease.

The patient's husband of 50 years died three years earlier. She lives alone. She has two daughters and granddaughters. She drinks 4 shots hard liquor/day, no tobacco, no illicit drugs.

Norvasc
Amitriptyline
Fentanyl
Prevacid
Flagyl
Prednisone
Pentasa

NKDA

Positive for colicky abdominal pain, roughly localized to the left lower quadrant. No pertinent pulmonary, cardiac, neurologic, rheumatologic, or renal responses.

* The patient is a well-nourished female in moderate distress.
* Vital signs: T=36.5 C, HR=84, RR=24, BP=176/92, O2 saturation 95% on RA.
* Head and Neck: Sclerae anicteric, oropharynx clear, no lymphadenopathy, no thyromegaly
* Lungs: Clear to ausculatation
* Cardiovascular: Regular rate, no murmurs, rubs or gallops
* Abdomen: Soft and protuberant. Bowel sounds present. Diffusely tender, left greater than right. No rebound or guarding. Liver palpated 3 cm below right costal margin. No palpable masses or splenomegaly. Stool negative for occult blood.
* Extremities: 1+ pitting edema in bilateral lower extremities.

WBC 12,700, Hgb 16, Plt 347,000, Glucose 248, Na 141, Cl 96, K 3.3, Anion gap 23, Lactic acid 2.3, Amylase 38, Lipase 22. Urinalysis negative.

Normal sinus rhythm @ 80 bpm, sinus arrhythmia, +U waves, delayed R wave progression

Abdominal X-ray shows three dilated small bowel loops in the left mid abdomen, no air or fluid level. Abdominal CT with oral and iv contrast showed distal small bowel thickening and an inflammatory mass in the right lower quadrant (Image 1). Two small, hypervascular lesions were identified in the liver (Image 2).

Colonoscopy performed upon admission to The Johns Hopkins Hospital showed an ileocecal valve mass. The patient's severe abdominal pain was managed with morphine. Initial biopsies of the colon and ileocecal mass were non- diagnostic. Surgery was consulted.

What is the next procedure for evaluation of the abnormal findings?
What is your differential diagnosis?