An unusual cause of abdominal pain in an elderly woman.

Department of Radiodiagnosis and Imaging and Department of Gastroenterology, Postgraduate Institute of MedicalEducation and Research (PGIMER), Chandigarh, IndiaQuestion: A 70-year-old woman presentedwith acute epigastricpain radiating to theback associated withdifficulty in breathing.There were few epi-sodes of vomiting overthe last 2 days. Therewas no associated feveror jaundice. No similarepisodeshadbeenre-ported previously.On examination,there was mild pallor.No icterus was present.Abdominal examina-tion revealed mild tenderness in the epigastrium. Other findings on systemic examination were a dull note on the left side ofchest with added sounds on auscultation. Total (1.8 mg/dL) and direct bilirubin (1.2 mg/dL) were mildly elevated. Routinehematologic investigations were unremarkable except for mild anemia (10 g/dL). There was elevation of serum amylase(660 IU/L). A diagnosis of acute pancreatitis was considered. Abdominal ultrasonography failed to visualize the pancreas.However, there were no gallstones. Other workup for acute pancreatitis, including history of alcohol/ drug intake, lipidprofile, and serum calcium, was negative.Contrast-enhanced multidetector (MD)CT of the abdomen revealed bulky pancreas (Figure A, B, arrows) in an abnormalposition. Similarly, the collapsed stomach (Figure A, short arrows) and spleen (Figure A, B, arrow head) was found in anabnormal position. The superior mesenteric artery (Figure A, thin arrow) showed an abnormal orientation. There was milddilatation of the common bile duct (Figure B, long thin arrow) and the main pancreatic duct (Figure B, long thick arrow).What is your diagnosis?See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favoriteimage to Clinical Challenges and Images in GI.