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An unusual case of epigastric pain

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3689 (Published 09 June 2014) Cite this as: BMJ 2014;348:g3689
  1. Yanushi Dullewe Wijeyeratne, National Institute for Health Research academic clinical fellow in cardiology12,
  2. Nicola Walters, consultant physician, respiratory and general medicine1
  1. 1St George’s Hospital, London SW17 0QT, UK
  2. 2Cardiovascular and Cell Sciences Research Institute, St George’s University of London, London SW17 0RE, UK
  1. Correspondence to: Y D Wijeyeratne ywijeyer{at}sgul.ac.uk

A 56 year old man presented with a seven day history of worsening epigastric pain associated with nausea and belching. He had a history of splenectomy (after trauma), hyperlipidaemia, obesity, and Bell’s palsy. Abdominal computed tomography in 2007 had shown multiple abdominal nodules consistent with splenunculi but nothing else of note (splenunculi are accessory “miniature spleens” composed of normal splenic tissue that can partially compensate and take over the vital functions of the spleen after splenectomy). He had recently been prescribed orlistat to facilitate weight loss and had been taking the drug for about 10 days before the onset of symptoms.

On examination, he was haemodynamically stable, his temperature was 37.5°C, and his abdomen was soft but tender in the epigastric region and left iliac fossa. Digital rectal examination did not identify blood, masses, or melaena. Blood tests showed a mild neutrophilia (8.4×109/L; reference range 1.7-8.0) and raised C reactive protein (102.4 mg/L; 0-7.5; 1 mg/L=9.52 mmol/L), but normal liver biochemistry, renal function, and concentrations of amylase and lipase. While awaiting inpatient oesophagogastroduodenoscopy, his inflammatory markers deteriorated (increased) and his abdominal pain persisted, even though he was given appropriate analgesia and a high dose of a proton pump inhibitor. Contrast enhanced computed tomography of his abdomen was arranged to rule out an intra-abdominal collection (figs 1 and 2).

Questions

  • 1. What do the images show?

  • 2. What is the diagnosis?

  • 3. What further investigations would you undertake after you make the diagnosis?

  • 4. What treatment would you start?

  • 5. What are the potential complications of this condition?

Answers

1. What do the images show?

Short answer

The figures show non-occlusive acute venous thrombosis in the portal and mesenteric veins.

Long answer

Computed tomography showed no evidence of a collection but the appearances of the portal and mesenteric veins were in keeping with non-occlusive acute venous thrombosis (figs …

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