An unusual cause of epigastric pain in a diabetic patient

Clinical presentation

A 47 year old woman presented with a three day history of fever and epigastric pain. She had a past medical history of diabetes mellitus regularly controlled by oral hypoglycaemic agents.

Clinically, she had a temperature of 38.7°C. Tenderness could be elicited in the epigastrum and right upper quadrant. Blood investigations revealed a left shift leucocytosis (leucocytes 17980/mm³, neutrophil 88%), hyperglycaemia (capillary sugar 424 mg/dl), negative blood and urine ketone body test, normal serum amylase(6 U/l) and lipase (8 U/l) levels, and abnormal liver function tests (total bilirubin 10.3 µmol/l, alkaline phosphatase 274 U/l, gamma glutamyl transferase 258 U/l, aspartate aminotransferase 64 U/l, and alanine aminotransferase 136 U/l). Abdominal radiograph showed a large region of mottled radiolucency centred at the epigastrum (fig 1, arrow).

Figure 1 Abdominal radiograph showed a large region of mottled radiolucency centred at the epigastrum (arrow).

Question

What is the diagnosis? What are the pathogenetic mechanisms of this condition?

See page 528 for answer

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