Calcifications in the upper abdomen.

www.aafp.org/afp Volume 84, Number 1 ◆ July 1, 2011 A 48-year-old woman presented to the emergency department with nausea, vomiting, and intermittent abdominal pain that had persisted for two days. The pain radiated from the epigastrium and left upper quadrant to her back. Nothing relieved the pain, and eating made it worse. The patient noted having two or three foul-smelling, loose stools during the previous two days. She denied fever or the presence of blood or mucus in her stools. Her medical history included type 2 diabetes mellitus requiring insulin therapy, alcoholism, many years of chronic abdominal pain, and chronic diarrhea. She had a cholecystectomy several years prior. On examination, she was afebrile, her blood pressure was 130/80 mm Hg, her pulse was 96 beats per minute, and her respiratory rate was 16 breaths per minute. The patient appeared malnourished. She had tenderness in the epigastrium and left upper quadrant, but no rigidity or guarding. She had hyperactive bowel sounds, but no abdominal bruits or palpable masses. Her cardiac and pulmonary examinations were unremarkable. She had a blood glucose level of 250 mg per dL (13.88 mmol per L). Her liver function tests, amylase level, lipase level, complete blood count including white blood cell count and differential, and lipid panel were normal. Her albumin and prealbumin levels were low at 2.5 g per dL (25 g per L) and 8 mg per dL (80 mg per L), respectively, and her A1C level was 7.5 percent. Supine and erect abdominal radiography was performed (Figures 1 and 2).