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A cutaneous manifestation of intra-abdominal disease

BMJ 2014; 349 doi: (Published 17 September 2014) Cite this as: BMJ 2014;349:g5492
  1. Lydia Burland, specialist trainee year 1, paediatrics1,
  2. Ben L Green, foundation year 2 doctor, academic vascular surgery2
  1. 1Bradford Royal Infirmary, Bradford, UK
  2. 2Leeds Teaching Hospitals Trust, Leeds LS1 3EX, UK
  1. Correspondence to: B L Green blgreen{at}

A 49 year old man presented to the emergency department with acute onset pain in the right upper quadrant and epigastric pain radiating to his back. Over the past 24-36 hours he had experienced nausea and vomiting as well as dark urine and pale stools, and he had developed several painful lumps on his abdomen and upper limbs.

On examination his abdomen was soft but notably tender in the epigastrium and right upper quadrant, with no palpable intra-abdominal masses or organomegaly. Tender, erythematous, subcutaneous nodules were noted across the trunk and upper limbs. Blood tests on admission showed that he had deranged liver function tests, as well as a raised amylase (20.8 µkat/L; reference range <1.67) and C reactive protein (1181 nmol/L; <95). His full blood count and urea and electrolytes were normal. Urine analysis was positive for bilirubin and protein.

Abdominal ultrasound showed a thick walled gallbladder containing several small calculi. Magnetic retrograde cholangiopancreatography (MRCP) showed a contracted gallbladder containing several stones (fig 1), a common bile duct dilated to a maximal diameter of 6 mm with no visible stones or filling defects, and areas of likely subcutaneous fat necrosis throughout the abdominal wall and upper limbs.

Fig 1 Magnetic retrograde cholangiopancreatogram showing the descending duodenum (A), gallstones within the contracted gall bladder (B), a cystic duct (C), the right hepatic duct (D), left hepatic duct (E), common hepatic duct (F), and common bile duct (G)


  • 1. What is the likely underlying diagnosis?

  • 2. What is the definitive treatment for this patient’s condition?

  • 3. What …

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