Gastroenterology clinical image challenge: A 63-year-old man was admitted from the emergency room with complains of nausea, fever and pain in the upper left abdominal quadrant. He had previous history of acute myocardial infarction, pulmonary emphysema, type II diabetes mellitus and arterial hypertension. On physical examination the patient had a fever, was hypotensive and tachycardic and had left upper abdominal quadrant tenderness. Laboratory investigation revealed neutrophilic leukocytosis (14,000/m3 white blood cells and 11,500/m3 neutrophils), an increase of C-reactive protein (180 mg/dL) and a slight elevation of bilirubin levels (total bilirubin 1.8 mg/dL and direct bilirubin 1.0 mg/dL). An abdominal computed tomography scan was obtained revealing the diagnosis (figure), which prompted endoscopic evaluation.
What is the diagnosis?
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