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).