Case 273

HistoryA 55-year-old man with a history of chronic pancreatitis secondary to chronic alcohol abuse presented to the hospital with acute abdominal pain, generalized weakness, weight loss, and pyrexia. A clinical examination revealed he was tender to touch in the upper abdomen. Laboratory tests revealed a serum alkaline phosphatase level of 370 U/L (6.1 µkat/L) (normal range, 30-130 U/L [0.5-2.2 µkat/L]), a lipase level of 172 U/L (2.9 µkat/L) (normal range, 0-60 U/L [0-1.0 µkat/L]), a C-reactive protein level of 159 mg/L (1514 nmol/L) (normal value, <8.0 mg/L [76.2 nmol/L]), and a white cell count of 7 × 10⁹/L (normal range, [4-11] × 10⁹/L). During the present admission, the patient underwent urgent CT for his acute symptoms. His relevant medical history included a hospital admission 2 months earlier for abdominal discomfort. Given his history of chronic pancreatitis, baseline abdominal MRI was performed to determine the cause of his symptoms and to assess the pancreas (Figs 1-3).Figure 1a:(a, b) Images from axial fat-suppressed T2-weighted MRI (repetition time msec/echo time msec, 1000/87; section thickness, 6 mm) of the upper abdomen obtained 2 months prior to admission. (c, d) Images from axial fat-suppressed T1-weighted MRI (3.69/1.62; section thickness, 4 mm) of the upper abdomen acquired 60 seconds after intravenous administration of gadopentetate dimeglumine (0.1 mL per kilogram of body weight; Magnevist; Bayer Healthcare, East Mississauga, Ontario) during the current admission.Figure 1b:(a, b) Images from axial fat-suppressed T2-weighted MRI (repetition time msec/echo time msec, 1000/87; section thickness, 6 mm) of the upper abdomen obtained 2 months prior to admission. (c, d) Images from axial fat-suppressed T1-weighted MRI (3.69/1.62; section thickness, 4 mm) of the upper abdomen acquired 60 seconds after intravenous administration of gadopentetate dimeglumine (0.1 mL per kilogram of body weight; Magnevist; Bayer Healthcare, East Mississauga, Ontario) during the current admission.Figure 1c:(a, b) Images from axial fat-suppressed T2-weighted MRI (repetition time msec/echo time msec, 1000/87; section thickness, 6 mm) of the upper abdomen obtained 2 months prior to admission. (c, d) Images from axial fat-suppressed T1-weighted MRI (3.69/1.62; section thickness, 4 mm) of the upper abdomen acquired 60 seconds after intravenous administration of gadopentetate dimeglumine (0.1 mL per kilogram of body weight; Magnevist; Bayer Healthcare, East Mississauga, Ontario) during the current admission.Figure 1d:(a, b) Images from axial fat-suppressed T2-weighted MRI (repetition time msec/echo time msec, 1000/87; section thickness, 6 mm) of the upper abdomen obtained 2 months prior to admission. (c, d) Images from axial fat-suppressed T1-weighted MRI (3.69/1.62; section thickness, 4 mm) of the upper abdomen acquired 60 seconds after intravenous administration of gadopentetate dimeglumine (0.1 mL per kilogram of body weight; Magnevist; Bayer Healthcare, East Mississauga, Ontario) during the current admission.Figure 2:Coronal T2-weighted MRI (repetition time msec/echo time msec, 1000/89; section thickness, 4 mm) of the upper abdomen obtained 2 months prior to admission.Figure 3:Coronal CT image of the abdomen acquired 60 seconds after administration of intravenous contrast material (100 mL of iohexol, Omnipaque 350; GE Healthcare, Princeton, NJ). This CT examination was performed during the current admission.