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DIS 5.5.0 DTD YGAST61209 proof 23 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 Question: A 65-year-old woman presented to emergency department with progressively worsening abdominal pain and diarrhea. She reports her symptoms started 8 months ago but have progressed to include nausea, vomiting, decreased appetite, and a 13-lb weight loss. She has never had a colonoscopy or endoscopy. Her past medical history consists of hyperlipidemia, asthma, and anxiety. On clinical examination, a middle-aged female was noted in mild discomfort, auscultation of the heart and lungs revealed no abnormalities, abdominal examination was pertinent for epigastric tenderness with no rebound or guarding, and normal bowel sounds were appreciable. Laboratory studies revealed a leukocytosis of 14 10/mL, hemoglobin of 8.4 g/dL, alkaline 84 85 86 87 88 89 90 91 phosphatase of 166 IU/L, and an International Normalized Ratio of 1.41. To further evaluate her symptoms, she had a computed tomography scan of the abdomen and pelvis with intravenous contrast (Figure A), which demonstrated focal colonic wall thickening at the distal transverse colon (blue arrow), at the hepatic flexure, which was inseparable from the greater curvature of the stomach (red arrow). She was started on pantoprazole intravenous infusion and admitted for further workup. What is the diagnosis and what would be your next step be? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 92 93 94 95 96 97 98 Conflicts of interest The authors disclose no conflicts.