A previously well 43-year-old men was admitted with right upper quadrant and epigastric pain, fever and vomiting. His medical history included asymptomatic cholestatic liver function tests for which serial ultrasound (US), magnetic resonance cholangiopancreatography, fibroscan and a US-guided liver biopsy had proved unremarkable several years prior to this presentation.

Physical examination revealed diffuse abdominal tenderness worst in the right upper quadrant and epigastric region. Laboratory investigations demonstrated raised inflammatory markers and deranged liver function but were otherwise unremarkable. CT of the abdomen and pelvis showed extensive pancreatic stranding and fluid most prominent around the tail and body of the pancreas. The patient had no history of gallstones, alcohol misuse, new medications, family history or hypercholesterolemia.

The patient was managed conservatively but subsequently deteriorated with features of abdominal sepsis.

Serial …