A cutaneous manifestation of intra-abdominal disease

A 49 year old man presented to the emergency department with acute onset pain in the right upper quadrant and epigastric pain radiating to his back. Over the past 24-36 hours he had experienced nausea and vomiting as well as dark urine and pale stools, and he had developed several painful lumps on his abdomen and upper limbs.

On examination his abdomen was soft but notably tender in the epigastrium and right upper quadrant, with no palpable intra-abdominal masses or organomegaly. Tender, erythematous, subcutaneous nodules were noted across the trunk and upper limbs. Blood tests on admission showed that he had deranged liver function tests, as well as a raised amylase (20.8 µkat/L; reference range <1.67) and C reactive protein (1181 nmol/L; <95). His full blood count and urea and electrolytes were normal. Urine analysis was positive for bilirubin and protein.

Abdominal ultrasound showed a thick walled gallbladder containing several small calculi. Magnetic retrograde cholangiopancreatography (MRCP) showed a contracted gallbladder containing several stones (fig 1⇓), a common bile duct dilated to a maximal diameter of 6 mm with no visible stones or filling defects, and areas of likely subcutaneous fat necrosis throughout the abdominal wall and upper limbs.