A 52 year old previously healthy Afro-Caribbean woman was admitted as an emergency with a 12 hour history of epigastric pain. She was a non-smoker, denied alcohol use, and had no significant comorbidity. Heart rate, respiratory rate, and temperature were normal at presentation. Abdominal examination revealed mild epigastric tenderness with guarding. Baseline investigations (full blood count, clotting, urea and electrolytes, and liver function tests) were within normal limits, except for a raised white cell count (12.1 (normal range 4–11)×10⁹/l (neutrophilia)) and a raised amylase level (2409 (normal <220) U/l). Abdominal and chest x rays were also normal. She was diagnosed with acute pancreatitis and treated supportively with intravenous fluids, analgesia, and thromboprophylaxis.

Twelve hours after admission the patient deteriorated significantly, with signs …