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A 25-year-old woman was under investigation for a 16 month history of severe right upper quadrant pain associated with nausea and vomiting which usually came on after meals. On examination there was pronounced right upper quadrant tenderness which was exacerbated by tensing of her abdominal musculature. A hepato-iminodiacetic acid (HIDA) scan was arranged which demonstrated prominent biliary stasis within the biliary tree and liver parenchyma in addition to incomplete drainage form the common bile duct. This raised the strong possibility of biliary dyskinesia. As a result an endoscopic retrograde cholangiopancreatography (ERCP) was arranged with sphincter of Oddi manometry.
During the procedure the patient experienced discomfort on cannulating the pancreas with pancreatic pressures averaging 30 mm Hg. Post-procedure the patient complained of upper abdominal pain radiating to her back which she described as being sharp and constant. She also experienced four episodes of vomiting which was essentially bile stained. Blood investigations revealed an amylase of 1802 iu/l, C reactive protein (CRP) of 234 mg/l, white cell count of 22.3×109/l, and calcium of 1.57 mmol/l. The patient was diagnosed with pancreatitis post-ERCP and placed on intravenous cefuroxime and metronidazole.
Two days later the patient became notably drowsy. She complained of generalised severe abdominal tenderness and bloating. She was pyrexic with a temperature of 38.2°C, a pulse rate of 135 beats/min and blood pressure of 82/52 mm Hg. On examination her abdomen was grossly distended and tender with absent bowel sounds. There was no evidence of rebound tenderness or peritonism. Routine blood investigations showed a haemoglobin of 5.9 g/dl, white cell count of 12.6×109/l, CRP of 233 mg/l, amylase of 95 iu/l, alkaline phosphatase (ALP) of 121 U/l, alanine aminotransferase (ALT) of 16 U/l, gamma glutamyl transferase (GGT) of 156 U/l, and calcium of 1.83 mmol/l.
The patient underwent an urgent computed tomography (CT) scan of the abdomen. The CT scan (fig 1) demonstrated a fairly large subcapsular haematoma in the perisplenic region, distorting the shape of the spleen and pushing it medially. In addition there was extensive peripancreatic fat stranding and fluid noted around the liver. There was no evidence of peripancreatic collections and no evidence of portal vein thrombosis.
The patient was managed conservatively with fluid and blood resuscitation. Over the next week she remained stable with no further haemodynamic compromise and was subsequently discharged.
We apologise that the following author was not included in the published case report.
Rhys Cottle, The Royal London Hosptial, Barts and the London NHS Trust, London, E1 1 BB, UK.
Competing interests: none.
Patient consent: Patient/guardian consent was obtained for publication
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