An unusual late complication of gastric surgery.

Nail-patella syndrome is a rare autosomal dominant disorder with characteristic skeletal and renal abnormalities, most commonly dysplastic nails, hypoplastic/absent patellae, and asymptomatic urinary abnormalities Box 3 Final diagnosis Nail-patella syndrome or hereditary onycho-osteodysplasia. A 52-year-old man presented with a history of colicky epigastric pain, intermittent upper abdominal distention and diarrhoea worsening over a period of six months. Over 20 years previously a vagotomy and pyloroplasty had been performed for a chronic duodenal ulcer after which he complained of similar symptoms to the above. These were attributed to dumping syndrome, and settled with simple dietary advice at that time. Initial investigation involved full blood count, urea and electrolytes (which were normal) and a barium meal examination (figure 1). Question What is the most probable diagnosis?