An Octogenarian With Acute Epigastric Pain: More Than Meets the Eye

Abstract

Question: An 84-year-old woman with a history of dementia and gastroesophageal reflux disease presented to the emergency department with several hours of worsening chest and epigastric pain associated with nausea and vomiting. Upon arrival she was hypertensive to 218/110 mm Hg and had a low-grade fever of 37.8 C. Physical examination was remarkable for epigastric tenderness in a cachectic, elderly woman with mild cognitive impairment. Electrocardiogram and cardiac enzymes ruled out acute coronary syndrome. Further evaluation revealed leukocytosis to 16.1 10/L and markedly abnormal serum liver tests with aspartate aminotransferase of 632 U/L, alanine aminotransferase of 548 U/L, alkaline phosphatase of 309 U/L, and total of bilirubin 1.9 mg/dL. Lipase was at the upper limit of normal. A chest radiograph showed a diaphragmatic hernia without evidence of free air (Figure A). Abdominal ultrasonography showed multiple small choleliths (without signs of acute cholecystitis) and mildly dilated extrahepatic and intrahepatic bile ducts. Cross-sectional imaging was subsequently obtained (Figure B and C) and demonstrated a “double-duct sign” (Figure C), a large diaphragmatic hernia, and an additional critical finding. Based on this patient’s symptoms, serum biochemical tests, and imaging findings, what is the likely etiology of her acute clinical presentation? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.