An Unusual Cause of Severe Epigastric Pain

Abstract

Question: A 47-year-old man with an unremarkable medical history presented to our emergency department with severe epigastric pain. He reported eating raw chub mackerel pieces (sashimi) 7 hours before symptom onset. His vital signs were stable and his body temperature was 36.9 C. He had no abdominal tenderness despite severe spontaneous pain. Laboratory findings revealed an elevated white blood cell count (13.8 Â 10 3 /mL) and C-reactive protein concentration (1.03 mg/dL). No ischemic change was detected on an electrocardiogram. An abdominopelvic computed tomographic examination revealed no abnormalities in the abdominopelvic cavity; however, a low-density area around the lower esophagus was visible. We also ordered a chest computed tomography scan, which showed edematous thickening of the entire length of the esophageal wall surrounded by fluid (Figure A, B). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.