Radiological case of the month

A 56-year-old woman with recently diagnosed pancreatic cancer presented with hematemesis and epigastric pain radiating to the back. She had completed 3 cycles of chemotherapy and radiation. A contrast-enhanced CT scan 2 weeks prior had demonstrated a large necrotic mass arising from the pancreatic body and tail, thrombosis of the superior mesenteric vein, partial occlusion of the portal vein, and a thickened stomach wall (figure 1). In addition, there was intrahepatic biliary duct dilatation with a dilated, thick-walled gallbladder and metastatic disease in the liver and lungs. On the day of admission, she was afebrile, dehydrated and tachycardic. Her abdomen was diffusely tender and guarded with absent bowel sounds. Laboratory data included an elevated white blood cell (WBC) count (42,000/mm³ with 98% neutrophils), prolonged prothrombin time (22 sec), and elevated liver enzymes. Serum amylase and lipase were normal.