Case history/examination
A 56-year-old Japanese woman, with chronic upper abdominal pain and
discomfort, consulted our emergency department for sudden epigastric
pain. One day prior to her presentation, she developed mild epigastric
pain, which improved spontaneously. Two hours before presentation, the
pain recurred suddenly after defecation. The pain was severe and waxed
and waned in severity. She also reported sweating. She denied having
chest pain, back pain, nausea/vomiting, diarrhea, melena, and
hematochezia. She had been treated for several years for chronic upper
abdominal pain, without any findings in upper endoscopy. Her medical
history included well-controlled hyperlipidemia. She had no history of
recent trauma. Her medication included omeprazole, domperidone, and
rosuvastatin. She occasionally consumed alcohol and had never smoked
cigarettes. On admission, her blood pressure was 115/74 mmHg, heart rate
was 63 beats/min, respiratory rate was 28 breaths/min, and the
temperature was 35.4 °C. She was in acute distress with severe pain.
Physical examination revealed epigastric tenderness, without peritoneal
signs. Laboratory data revealed leukocytosis, elevated liver enzyme
levels, and hyperlactatemia. Results of laboratory examination and
arterial blood gas analysis on admission are presented in Table 1.
Abdominal contrast-enhanced computed tomography (CT) revealed
retroperitoneal hemorrhage surrounding the duodenum and pancreas (Figure
1A) and celiac artery narrowing (Figure 1B).