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DIS 5.4.0 DTD YGAST60986 proof 30 June 2017 2:55 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 Question: A 54-year-old man was referred to our hospital with a 1-month history of intermittent tarry to bloody stool. His medical history included hepatitis B–related liver cirrhosis and hepatocellular carcinoma (HCC). His hepatoma was diagnosed 1 year earlier (American Joint Committee on Cancer Staging T3aN0M0) , and he was treated with radiofrequency ablation and tumor embolization. The tumor recently progressed with portal vein tumor thrombosis (Figure A). He underwent sorafenib therapy; however, the drug was discontinued after the bleeding episode. 87 88 89 90 91 92 93 94 95 Examination with upper endoscopy and colonoscopy failed to identify the cause of bleeding. Despite medical therapy, including a proton pump inhibitor and octreotide, the bleeding persisted, and he was referred to our hospital for deep enteroscopy. The laboratory examination revealed anemia (hemoglobin 9.1 g/dL), thrombocytopenia (platelet count, 131 10/L), and a normal prothrombin time. The calculated Model for End-stage Liver Disease score was 8 and the Child-Pugh class was B. Deep enteroscopy via the anal route was performed, and a lesion at 100 cm from the ileocecal valve was found (Figure B, Video Clip A). What are the findings of enteroscopy? What is the differential diagnosis? Look on page 000 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. 96 97 98 99 Conflicts of interest The authors disclose no conflicts.