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A previously fit and well 43-year-old male triathlete presented with severe central abdominal pain persisting for several hours. Three similar episodes in the past 18 months had spontaneously resolved. Prior investigations with abdominal ultrasound, upper and lower GI endoscopies had been unremarkable. On this presentation, the patient also had worsening malaise and fever at 40°C. He was fluid resuscitated and commenced on broad-spectrum antibiotics (intravenous piperacillin–tazobactam 4.5 g and 350 mg gentamicin).
Initial biochemistry revealed absolute eosinophil count 0.56×109/L, asparate aminotransferase serum 72 IU/L and alanine aminotransferase (ALT) 78 IU/L. The alkaline phosphatase 65 IU/L, bilirubin 10 μmol/L, white cell count 7.93×109/L and C-reactive protein 5 mg/L were all normal. CT abdomen (figure 1A) did not reveal gallstones nor any small bowel pathology. As the …