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Unusual subcutaneous manifestation of severe acute pancreatitis.

We report the case of an eighty-nine-year old Caucasian male who was seen in our emergency department after consulting for abdominal pain, nausea and vomiting for two days. His medical background included typhoid fever and peptic ulcer. After physical examination, pain and abdominal tenderness were observed without peritoneal irritation signs. Rutine blood test were performed: white blood count 20,500/mL (78% neutrophils), 42% hematocrit, prothrombin activity 80%, fibrinogen 600 mg/dl, bilirubin 3.3 mg/dl, amylase 229 U/l, lipase 310 U/l, GPT 141 mg/dl; urine analysis and chest X-rays showed no significative findings. An abdominal CT scan was performed which revealed acute pancreatitis with three fluid collections without necrosis (Balthazar’s score grade E). Moreover, an important omental inflammatory infiltration was observed. The greater omentum experienced a ventral displacement and was attached to the anterior abdominal wall (Fig. 1). The patient was hemodinamically stable and met no Intensive Care Unit admission criteria. After three days of uneventful hospital stay the patient developed an epigastric subcutaneous hematoma that was different from the classic Cullen and Gray-Turner signs (Fig. 2). This clinical finding disappeared spontaneously after 15 days. Both clinical and radiological (sequential CT scans) inpatient follow-up showed an excellent outcome. The patient was discharged after 40 days in our site. PICTURES IN DIGESTIVE PATHOLOGY