Endgames Picture Quiz

A rare cause of abdominal pain

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c2112 (Published 12 May 2010) Cite this as: BMJ 2010;340:c2112
  1. Clare Anderson, foundation year one doctor,
  2. Hugh Colvin, core trainee year one
  1. 1Sunderland Royal Hospital, Sunderland SR4 7TP
  1. Correspondence to: C Anderson canderson.newcastle{at}googlemail.com

    A 28 year old injecting drug user presented to the hospital with non-specific symptoms of abdominal pain and fever. Clinical examination showed diffuse abdominal tenderness, most prominent in the left upper quadrant, with localised guarding and rigidity. One month earlier he had presented with a septic iliofemoral vein thrombosis and was started on warfarin. A portable chest radiograph was limited but unremarkable and did not show subphrenic air. Blood tests showed anaemia, consistent with his previous admission, and raised inflammatory markers of white blood cell count 19.88×109/l and C reactive protein 77 mg/l. He underwent computed tomography of the abdomen (fig 1).

    Fig 1 Computed tomogram of the abdomen

    Questions

    • 1 What abnormality can be seen on computed tomography and what are the possible causes?

    • 2 What aetiological factors can predispose patients to this condition?

    • 3 What treatment options are available?

    Answers

    1 What abnormality can be seen on computed tomography and what are the possible causes?

    Short answer

    A 6 cm low attenuation lesion can be seen in the posterior parenchyma of an enlarged spleen (fig 2). A left pleural effusion was also present. The possible causes of a low attenuating splenic lesion include splenic infarction, haematoma, tumour, and complicated cyst. In this clinical scenario, splenic abscess is the most likely cause.

    Fig 2 Computed tomogram of the abdomen showing a low attenuation lesion in the posterior parenchyma of an enlarged spleen (arrow)

    Long answer

    Computed tomography …

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