CASE 69: ABDOMINAL PAIN
History
A 58-year-old woman consults her general practitioner (GP) with a 2-month history of
intermittent dull central epigastric pain. It has no clear relationship to eating and no radi-
ation. Her appetite is normal, she has no nausea or vomiting and she has not lost weight.
Her bowel habit is normal and unchanged. There is no relevant past or family history. She
has never smoked, and drinks alcohol very rarely. She has worked all her life as an infant
school teacher. Physical examination at this time was completely normal, with a blood pres-
sure of 128/72 mmHg. Investigations showed normal full blood count, urea, creatinine and
electrolytes, and liver function tests.
An H 2 antagonist was prescribed and follow-up advised if her symptoms did not resolve.
There was slight relief at first, but after 1 month the pain became more frequent and
severe, and the patient noticed that it was relieved by sitting forward. It had also begun
to radiate through to the back. Despite the progressive symptoms she and her husband
went on a 2-week holiday to Scandinavia which had been booked long before. During the
second week her husband remarked that her eyes had become slightly yellow, and a few
days later she noticed that her urine had become dark and her stools pale. On return from
holiday she was referred to a gastroenterologist.
Examination
She was found to have yellow sclerae with a slight yellow tinge to the skin. There was no
lymphadenopathy and her back was normal. As before her heart, chest and abdomen were
normal.
Haemoglobin 15.3 g/dL 11.7–15.7 g/dL
White cell count 6.2% 109 /L 3.5–11.0% 109 /L
Platelets 280 % 109 /L 150–440% 109 /L
Sodium 140 mmol/L 135–145 mmol/L
Potassium 4.8 mmol/L 3.5–5.0 mmol/L
Urea 6.5 mmol/L 2.5–6.7 mmol/L
Creatinine 111 &mol/L 70–120&mol/L
Calcium 2.44 mmol/L 2.12–2.65 mmol/L
Phosphate 1.19 mmol/L 0.8–1.45 mmol/L
Total bilirubin 97 mmol/L 3–17 mmol/L
Alkaline phosphatase 1007 IU/L 30–300 IU/L
Alanine aminotransferase 38 IU/L 5–35 IU/L
Gamma-glutamyl transpeptidase 499 IU/L 11–51 IU/LINVESTIGATIONS
Questions
- What is the likely diagnosis?
- What further investigations should be performed?