The patient was an 82-year-old man with a past medical history of tuberculosis of the spine, treated 50 years earlier. He had an episode of acute gallstone pancreatitis in 2004 that was treated conservatively, and subsequently refused surgical intervention for his gallstone disease. He had no other significant medical history and did not consume alcohol or smoke. He presented with an acute onset of severe bilateral lower limb pain associated with paresthesia for one day's duration. He also complained of mild epigastric pain, abdominal distension and nausea for two days prior to the onset of lower limb pain. There was no previous history of claudication or cardiovascular risk factors such as family history, hyperlipidemia, or diabetes mellitus.
Physical examination revealed pale and cold lower limbs up to the level of mid thigh bilaterally with pulses absent in the posterior tibia, dorsalis pedis and the popliteal arteries bilaterally. Capillary refill was delayed to 5 s bilaterally. There was tenderness on deep palpation and mild guarding over his epigastrium associated with some abdominal distension with sluggish bowel sounds.
Laboratory investigation revealed leukocytosis (23.6 x 109/l), markedly elevated serum amylase levels (2,450 U/l) and lipase levels (5,265 U/l), high creatine kinase levels (8,556 U/l), and the arterial blood gas picture showed metabolic acidosis. Liver function revealed mild transaminitis and raised alkaline phosphatase (229 U/l) and a bilirubin level of 38 U/l. C-reactive protein was also elevated (45.6 mg/l). Ranson score was 5 on admission. In view of his findings, the diagnosis of acute pancreatitis and bilateral lower limb ischemia complicated by rhabdomyolysis was made.
Computed tomography of the abdomen revealed findings consistent with acute severe pancreatitis associated with choledocholithiasis and cholelithiasis. Computed tomographic angiography revealed occlusion of the left superficial femoral artery as well as the bilateral popliteal, tibial and peroneal arteries (fig. 1).
He was admitted to the surgical intensive care unit for management and started on intravenous fluids, antibiotics, and heparin, and was kept on a nil-by-mouth regime. The patient was offered bilateral above-knee amputations, which he initially refused. He improved clinically with these supportive measures, and the ileus resolved. Laboratory indicators also improved with normalization of liver enzymes, amylase levels, creatine kinase levels and blood gases (fig. 2). Ranson score at 48 h was 7. However, the ischemia of his lower limbs worsened and necessitated bilateral above-knee amputation during the same hospital admission. He recovered uneventfully post-operatively and was discharged well.