When numbers do not add up!
A 62-year-old gentleman was admitted to the surgical admissions unit in 2009 with a history of vomiting and abdominal pain on a background of abnormal renal (urea 13.6 mmol/l, creatinine 165 umol/l) and liver function tests (alanine transaminase 48 U/l, gamma glutamyl transaminase 100 U/l, alkaline phosphatase 156 u/l). Blood pressure was 170/120 mm Hg on admission and a 12-lead electrocardiogram (ECG) revealed sinus tachycardia and anterolateral ischaemia. Troponin I levels were elevated at 2.88 µg/l. A provisional diagnosis of acute cholecystitis and acute coronary syndrome was made by the admitting surgical team. Intravenous fluids and antibiotics were commenced followed by an improvement in patient’s condition.

Abdominal imaging revealed normal liver, gall bladder and a 5.4 × 5.6 cm mass …