Clinics in diagnostic imaging (176)

Abstract

A 52-year-old man presented to the emergency department with progressively worsening upper abdominal pain of one week's duration. He was a heavy smoker with a history of chronic heart disease and atrial fibrillation, but was not compliant with his warfarin therapy. An echocardiogram performed two months before had shown a thrombus in the left ventricular apex and left atrial appendage.The patient's vital signs included a heart rate of 122 beats per minute (irregularly irregular), blood pressure of 123/68 mmHg, respiratory rate of 20 breaths per minute and oxygen saturation of 99% on room air. He was afebrile, alert and showed no signs of distress. Pertinent physical findings included a soft abdomen with moderate tenderness elicited in the epigastrium and left hypochondrium. There was no rebound tenderness, guarding or abdominal distension. Bowel sounds were present. The remainder of the physical examination was non-contributory. Bedsidefocused ultrasonography showed no evidence of free fluid.Initial laboratory results showed a mildly raised white blood cell count of 10.4 × 10 9 /L and serum lactate level of 2.4 mmol/L (normal range 0.5-2.2 mmol/L). The patient's liver function test results were mostly within normal limits (alanine aminotransferase 12 U/L, aspartate aminotransferase 21 U/L, bilirubin 24 µmol/L, alkaline phosphatase 97 U/L), with the exception of mildly raised gamma-glutamyl transpeptidase (GGT) (61 U/L, normal range 7-50 U/L). His international normalised ratio was normal, measuring 1.2.Contrast-enhanced computed tomography (CT) of the abdomen was performed shortly after the patient was admitted. What do the CT images (Figs. 1-3