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  October 9, 2019

Image challenge: A rare complication of peptic ulcer disease

What caused a 74-year-old patient with recurrent pyloric stenosis to present with nausea, vomiting and weight loss?
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Gastroenterology clinical image challenge:  An 86-year-old woman with a history of open appendicectomy presented with epigastric and right upper quadrant pain, but no other symptoms. Physical examination showed right upper quadrant tenderness with positive Murphy sign. Laboratory tests revealed elevated white blood cell count of 16.1 g/L (normal, 4.5–11.5 g/L), C-reactive protein of 196 mg/L (normal, <10 mg/L), aspartate aminotransferase of 99 U/L (normal, 13-40 U/L), alanine aminotransferase of 80 U/L (normal, 7-40 U/L), gamma-glutamyl transferase of 127 U/L (normal, <38 U/L), alkaline phosphatase of 138 U/L (normal, 46-116 U/L) and total bilirubin of 26 μmol/L (normal, <21 μmol/L); pancreatic enzymes were within normal range. An abdominal computed tomography scan showed a fluid collection measuring 9.3 × 5.0 × 5.5 cm near the hepatic flexure, suspected to be the gallbladder with an atypical anatomical location (figure). A magnetic resonance cholangiopancreatography confirmed it was the gallbladder and highlighted a pericholecystic fluid collection indicating an acute cholecystitis.

What is the diagnosis? What should be the treatment?

To find out the diagnosis, read the full case in Gastroenterology.

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