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Chewing is an important first step in digestion
  1. R Slim,
  2. K Honein,
  3. C Yaghi,
  4. M Chemaly,
  5. B Kheir,
  6. R Sayegh
  1. Hotel Dieu De France Hospital, Achrafieh, Beirut, Lebanon
  1. Correspondence to:
    Dr R Slim
    Gastroenterology unit, Hotel Dieu de France University Hospital, Achrafieh, Beirut 00961, Lebanon; rslimkaram{at}

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Clinical presentation

A 52 year old man with a known history of renal stones presented with symptoms and signs of right renal colic. No fever or infectious signs were noted. Right ureteral stone impaction was diagnosed and treated by ureteroscopy and internal ureteral stenting. Twenty four hours later he complained of fever that occurred concomitantly with a vague crampy abdominal pain. An abdominal ultrasound was normal. Blood and urinary cultures were taken and a broad spectrum antibiotherapy was started for a presumed pyelonephritis. Fever subsided within 48 hours, cultures were negative, and the patient was discharged five days later.

The day after discharge he was readmitted to hospital for septicaemia. Physical examination showed high temperature with normal blood pressure and right upper abdominal tenderness.


An abdominal computed tomography scan was performed (figs 1, 2). What does it show?

See page 424 for answer

This case is submitted by:


  • Robin Spiller, Editor

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