case records of the massachusetts general hospitalThe new england journal of medicine n engl j med 348;15 www.nejm.A 14-year-old boy with a history of ulcerative colitis was admitted to the hospital because of vomiting and abdominal pain.Ulcerative colitis had been diagnosed at the age of three years by colonoscopic examination after a barium-enema examination had revealed no abnormalities. In subsequent years, progression of the disease was well controlled with the administration of mesalamine and short courses of an adrenocorticosteroid medication for flares; hospital admission was not required. The patient lived with his parents, two siblings, and a healthy dog. There was no family history of gastrointestinal or autoimmune diseases.
first admissionFourteen months before the current admission, abdominal pain, pruritus, and jaundice developed, and the patient was admitted to the hospital. An endoscopic retrograde cholangiopancreatographic study revealed evidence of primary sclerosing cholangitis with a dominant stricture, for which a stent was placed. Cytologic examination of biliary brush specimens disclosed bile-duct epithelium with reactive changes and no malignant cells. The procedure was complicated by pancreatitis. The results of laboratory tests are shown in Table 1. During a five-day hospital stay, the patient received morphine and prednisone, and his condition improved. He was discharged on the sixth hospital day.
second admissionFourteen weeks after discharge, the patient was admitted for the second time because of abdominal pain. Another endoscopic retrograde cholangiopancreatographic study was performed, with replacement of the old stent and a sphincterotomy. Examination of a core needle-biopsy specimen of the liver showed changes consistent with the presence of chronic active hepatitis. Antibiotics and hydrocortisone were given, but the next day epigastric and right-upper-quadrant pain developed, and the temperature spiked to 39.8°C. Two blood cultures were sterile, and the amylase and lipase levels remained normal. A chest radiograph showed only a linear opacity, consistent with atelectasis, in the left upper lobe. An abdominal ultrasonographic examination yielded no evidence of bileduct distention or leakage, and the hepatic parenchyma appeared normal; the pancreatic presentation of case The New England Journal of Medicine Downloaded from nejm.org on August 14, 2015. For personal use only. No other uses without permission.