Transcript
Page 1: Calcifications in the Upper Abdomen

92  American Family Physician www.aafp.org/afp Volume 84, Number 1 ◆ July 1, 2011

A48-year-oldwomanpresentedtotheemer-gencydepartmentwithnausea,vomiting,andintermittent abdominal pain that had per-sisted for two days. The pain radiated fromthe epigastrium and left upper quadrant toherback.Nothingrelievedthepain,andeat-ingmadeitworse.Thepatientnotedhavingtwoor three foul-smelling, loose stoolsdur-ingtheprevioustwodays.Shedeniedfeverorthepresenceofbloodormucusinherstools.Hermedicalhistoryincludedtype2diabetesmellitus requiring insulin therapy, alcohol-ism,manyyearsofchronicabdominalpain,andchronicdiarrhea.Shehadacholecystec-tomyseveralyearsprior.

On examination, she was afebrile, herbloodpressurewas130/80mmHg,herpulsewas96beatsperminute,andherrespiratoryratewas16breathsperminute.Thepatientappearedmalnourished.Shehadtendernessin the epigastrium and left upper quad-rant, but no rigidity or guarding. She hadhyperactivebowelsounds,butnoabdominalbruits or palpable masses. Her cardiac and

pulmonary examinations were unremark-able.Shehadabloodglucoselevelof250mgperdL(13.88mmolperL).Herliverfunctiontests, amylase level, lipase level, completebloodcountincludingwhitebloodcellcountanddifferential,andlipidpanelwerenormal.Heralbuminandprealbuminlevelswerelowat2.5gperdL(25gperL)and8mgperdL(80mgperL),respectively,andherA1Clevelwas7.5percent.Supineanderectabdominalradiographywasperformed(Figures 1 and 2).

QuestionBasedonthepatient’shistory,physicalexami-nation,andradiographicfindings,whichoneofthefollowingisthemostlikelydiagnosis?

❑A.Abdominalaorticaneurysm. ❑B.Acutebowelobstruction. ❑C.Chronicpancreatitis. ❑D.Mesentericlymphnode

calcifications. ❑E.Splenicarterycalcifications.

See the following page for discussion.

Calcifications in the Upper AbdomenJOHNR.McCONAGHY,MD,andRAMANAREDDYKANKANKALA,MBBS Department of Family Medicine, The Ohio State University College of Medicine, Columbus, Ohio

The editors of AFP wel-come submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors’ Guide at http://www.aafp.org/afp/ photoquizinfo. To be con-sidered for publication, submissions must meet these guidelines. E-mail submissions to [email protected]. Contributing edi-tor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.

A collection of Photo Quiz-zes published in AFP is available at http://www.aafp.org/afp/photoquiz.

Photo Quiz

Figure 2.Figure 1.

Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2011 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests.

Page 2: Calcifications in the Upper Abdomen

Photo Quiz

July 1, 2011 ◆ Volume 84, Number 1 www.aafp.org/afp American Family Physician  93

DiscussionAnswerC:chronicpancreatitis.Chronicpancreatitisisaninflammatorydiseasecharacterizedbyprogressivefibro-sisofthepancreasresultinginalossofitsexocrineandendocrine functions. The diagnosis is based on clinicalpresentation, laboratory findings, and imaging studies.The triad of steatorrhea, diabetes, and pancreatic calci-fications on abdominal radiography strongly suggeststhepresenceofchronicpancreatitis in thispatient.Theprevalenceofchronicpancreatitisisdifficulttoestimate,primarilybecauseacuteandchronicpancreatitisarecon-sidered to be part of a spectrum rather than individualentities. Risk factors for chronic pancreatitis includealcoholism, hyperlipidemia, hypercalcemia, smoking,autoimmune pancreatitis, and a genetic predispositionto chronic pancreatitis.1 Recurrent episodes of acutepancreatitis are usually the precursor to chronic pan-creatitis.2,3Mostpatientswithalcoholismandrecurrentpancreatitiswilldevelopchronicpancreatitisinapproxi-matelyfiveyears.1,2

Epigastric pain that radiates to the back is the mostcommon presenting symptom of chronic pancreatitis.4The pain can be intermittent or continuous and mayvary in severity. Amylase and lipase levels are elevatedduring acute attacks in the early phase of the disease,but may remain normal as the disease progresses to amorechronicstate.Astheconditionprogresses,patientsdevelopdeficienciesintheendocrineandexocrinefunc-tion of the pancreas due to fibrosis and calcifications.Thisresultsindiabetes5andfatmalabsorption,leadingtosteatorrheaandmalnutrition.

Thepancreasusuallycannotbevisualizedwithstan-dard abdominal radiography. However, in the laterstagesofchronicpancreatitis,calcificationsforminthepancreaticductsandthencanbeseenradiographically.6In thispatient, theabdominal radiographsshowcoarsecalcifications in a horizontal distribution over the first

and second lumbar vertebral bodies that extend to thepatient’sleftsideoverthetypicallocationofthepancreas(Figure 3).Thediagnosiscanbeconfirmedwithcontrast-enhancedcomputedtomographyoftheabdomen.1

Summary Table

Condition Findings on abdominal radiography

Abdominal aortic aneurysm Curvilinear rim of calcification in the wall of the aneurysm along the spine

Bowel obstruction Multiple air-fluid levels and dilated bowel loops (diameter greater than 1.2 in [3 cm] in small intestine, greater than 2.4 in [6 cm] in large intestine)

Chronic pancreatitis Spotted or mottled calcifications lying in a horizontal distribution over first and second vertebral bodies and extending into left upper quadrant of the abdomen

Mesenteric lymph node calcifications

Rounded or “popcorn” calcifications, mostly in the right midabdomen; calcifications appear to move inferiorly on upright abdominal films

Splenic artery aneurysms and calcifications

Splenic artery aneurysms appear like focal rounded calcifications in left upper quadrant, usually in conjunction with calcifications elsewhere in the artery; calcifications are usually serpiginous in nature

Figure 3. Abdominal radiography of a patient with chronic pancreatitis. Anterior views of the patient (A) standing and (B) supine show coarse calcifications (arrows) over the first and second lumbar vertebral bodies.

A

B

Page 3: Calcifications in the Upper Abdomen

Photo Quiz

94  American Family Physician www.aafp.org/afp Volume 84, Number 1 ◆ July 1, 2011

Photo Quiz

Calcificationsassociatedwithabdominalaorticaneu-rysmsareoften incidental findingson imagingstudiesand appear as a curvilinear rim of calcification in thewalloftheaneurysmalongthespine.

In patients with bowel obstruction, abdominal radi-ography shows dilated loops of bowel with multipleair-fluidlevelswithinthebowelloops,typicallywithoutcalcifications.

Mesenteric lymph node calcifications do not causeabdominalpainandareusuallysecondarytoaninfec-tion, an inflammatory process, or a malignancy else-whereinthebody.Abdominalradiographsdemonstrateroundedor“popcorn”calcificationsmostlyintherightmidabdomen and may appear to move inferiorly onuprightabdominalfilmsasthemesenterymoveinferi-orlyduetogravity.

Splenicarterycalcificationsandaneurysmsappearasfocal roundedcalcifications in the leftupperquadrant,usually in conjunction with calcifications elsewhere intheartery.7,8Thesecalcificationsarenotnormallyseeninahorizontaldistributionorinthemidlineoftheabdo-men,butaretypicallyserpiginousinnaturebecausethesplenicarteryisusuallytortuousinitscourse.

Address correspondence to John R. McConaghy, MD, at john. [email protected]. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations to disclose.

REFERENCES

1. Etemad B, Whitcomb DC. Chronic pancreatitis: diagnosis, classifi-cation, and new genetic developments. Gastroenterology. 2001;120(3):682-707.

2. Ammann RW. Diagnosis and management of chronic pancreatitis: cur-rent knowledge. Swiss Med Wkly. 2006;136(11-12):166-174.

3. Ahmed SA, Wray C, Rilo HL, et al. Chronic pancreatitis: recent advances and ongoing challenges. Curr Probl Surg. 2006;43(3):127-238.

4. Sakorafas GH, Tsiotou AG, Peros G. Mechanisms and natural history of pain in chronic pancreatitis: a surgical perspective. J Clin Gastroenterol. 2007;41(7):689-699.

5. Malka D, Hammel P, Sauvanet A, et al. Risk factors for diabetes mellitus in chronic pancreatitis. Gastroenterology. 2000;119(5):1324-1332.

6. Ammann RW. A clinically based classification system for alcoholic chronic pancreatitis: summary of an international workshop on chronic pancreatitis. Pancreas. 1997;14(3):215-221.

7. Vlychou M, Kokkinis C, Stathopoulou S, et al. Imaging investigation of a giant splenic artery aneurysm. Angiology. 2008;59(4):503-506.

8. Busuttil RW, Brin BJ. The diagnosis and management of visceral artery aneurysms. Surgery. 1980;88(5):619-624. ■


Recommended