Figure 1

A 40-year-old female presented to the emergency department with a one day history of increasing right upper quadrant pain and vomiting. The pain was sudden in onset, constant and severe. Clinical examination revealed localised tenderness in the right upper quadrant with a positive Murphy’s sign. Radiographs of the chest and abdomen were normal and the blood tests showed a normal haemoglobin level and an increased white cell count (WCC) of 15.5 x109/L, with a mild neutrophilia. The liver function tests were within normal limits, with a normal serum amylase and lipase. An upper abdominal ultrasound was performed, which revealed a normal gallbladder. She was admitted for observation and her abdominal pain progressively worsened over a period of 24 hours. A computed tomography (CT) scan of the abdomen and pelvis was performed (Figure 1)