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A 65 year old man presented to the accident and emergency department with a four week history of worsening pain in the right upper quadrant of his abdomen. There was no history of jaundice or change in appearance of his stools or urine. On admission, he was feversish with a temperature of 37.8°C and his abdomen was soft and non-tender. Blood tests revealed a neutrophilia of 16 with a raised C reactive protein at 180. Apart from an increased alkaline phosphatase of 160, the rest of the liver function tests were all within normal limits.
Ultrasound showed multiple gall stones with no evidence of biliary obstruction. A preliminary diagnosis of acute cholecystitis was made, and he was treated with intravenous antibiotics.
On the following day, he developed sudden onset flaccid paralysis of his right lower limb with acute urinary retention. Rectal examination revealed loss of contraction of the anal sphincter. Magnetic resonance imaging (see figs 1 and 2) confirmed the clinical diagnosis of cauda equina compression and at surgery, an epidural abscess was found compressing the spinal cord around T9/10. Laminectomy was performed to decompress the cord posteriorly and a costotransversectomy was also carried out to excise the ninth rib proximally allowing access to the abscess and its drainage. Instrumented posterior fusion of T6 to L1 was then performed.
Neurological symptoms in his lower limb improved considerably after a prolonged course of antibiotics and at three months he was able to stand with crutches.
This case illustrates several important learning points. Firstly, extra-abdominal pathology including those arising from the spine must be considered in the evaluation of a patient with abdominal pain.1 Secondly, liver function tests are not specific for liver disease, for example, alkaline phosphatase may also be raised in disease processes of bone, intestine and prostate. Finally, any patient presenting with acute neurological symptoms such as paralysis or a sensory level,2 requires urgent specialist referral as a delay in diagnosis and treatment correlates with a poor prognosis.3