Abdominal Discomfort, Altered Bowel Habits, and Weight Loss in a 13-year-old Girl.

1. Sydney Ariagno, MD* 2. Archana Jeeji† 3. Nathan Hull, MD‡ 4. Imad Absah, MD* 1. *Department of Pediatric and Adolescent Medicine 2. ‡Department of Radiology, Mayo Clinic, Rochester, MN 3. †Mayo Clinic School of Medicine, Rochester, MN A previously healthy 13-year-old girl is referred to pediatric gastroenterology by her primary care provider for evaluation of chronic generalized abdominal discomfort, early satiety, and bowel movements alternating between constipation and diarrhea. These symptoms have been worsening over a 4-month period. During these 4 months she has lost 40 lb and developed secondary amenorrhea. Physical examination is notable for emaciated appearance and abdominal tenderness in the right lower quadrant. Initial laboratory evaluation reveals a microcytic anemia with a hemoglobin level of 9.6 g/dL (96 g/L) (reference range, 11.9–14.8 g/dL [119–148 g/L]) and a mean corpuscular volume of 72.9 fL (reference range, 82.5–98.0 fL). Iron studies are suspicious for anemia of chronic inflammation, with a decreased serum iron level of 13 μg/dL (2.33 µmol/L) (reference range, 35–145 μg/dL [6.26–25.95 µmol/L]) and total iron-binding capacity of 199 μg/dL (35.62 µmol/L) (reference range, 250–400 μg/dL [44.75–71.60 µmol/L]), with a normal ferritin level of 275 ng/mL (275 μg/L) (reference range, 11–307 ng/mL [11–307 μg/L]). Her inflammatory markers are notably elevated, with an erythrocyte sedimentation rate of 72 mm/hr (reference range, 0–29 mm/hr) and a C-reactive protein level of 9.17 mg/dL (91.7 mg/L) (reference range, ≤0.8 mg/dL [≤8.0 mg/L]). Thyroid and hepatic function are normal. Celiac disease antibody panel and gastrointestinal (GI) pathogen panels are unrevealing. Fecal calprotectin level is elevated at 498 μg/g (reference range, ≤50 μg/g). Due to concern for an inflammatory GI process, the patient undergoes esophagogastroduodenoscopy and colonoscopy, of which the results are grossly normal. Biopsy results are normal. Two weeks after her initial outpatient evaluation she develops acutely worsening abdominal pain and new-onset vomiting. She presents to an outside facility, where an abdominal magnetic resonance enterography is performed. Although the imaging reveals no evidence to suggest a primary GI inflammatory process, bilateral, 4-cm, peripherally gadolinium-enhancing, adnexal masses are discovered, causing …