A 71-year-old woman presented with severe upper abdominal pain and vomiting for one day. She had undergone a left-sided hemi-hepatectomy due to liver metastases of a neuroendrocrine tumour of an unknown primary three weeks earlier. One week later, she received a percutaneous biliary drain due to a bile leak, and underwent endoscopic retrograde cholangiopancreatography (ERCP) with stent placement. Her medical history included cerebral vascular accident, appendectomy and mild pancreatitis. At presentation, the physical examination showed tachypnoea, direct and rebound tenderness of the right upper quadrant of the abdomen and normothermia. Laboratory analysis showed haemoglobin 6.6 mmol/l (reference range 7.5-10.0 mmol/l), leucocytes 40.1 x 109/l (reference range 4-10 x 109/l), neutrophils 37.9 x 109/l (reference range 1.5-9 x 109/l), bilirubin 179 µmol/l (reference range < 17 µmol/l), lactic acid 5.0 mmol/l (reference range 0.5-2.2 mmol/l), creatinine 119 mmol/l (67 mmol/l two weeks earlier) (reference range 50-90 µmol/l) and free haemoglobin 358 µmol/l (reference range < 0.16 µmol/l); due to massive haemolysis, liver enzymes and lactate dehydrogenase could not be measured. Haptoglobin was unfortunately not available either. The biliary drain produced some pus, but no bile. Blood cultures were drawn, an chest X-ray and a computed tomography (CT) scan of the abdomen were performed (figure 1).
WHAT IS YOUR DIAGNOSIS?