An unusual cause of abdominal pain

Gastroent Question: An 88year-old woman was admitted to our hospital complaining of upper abdominal and back pain. She had a history of hypertension. On admission, she was febrile with a temperature of 38.4 C, blood pressure was 122/54 mmHg, and her pulse rate was 84 beats per minute. Her abdomen was soft, nondistended, and nontender. Admission blood work revealed a white blood cell count of 7,800/mm. Her liver panel showed a total bilirubin of 1.1 mg/dL (normal, 0.1-1.1); alanine aminotransferase, 62 IU/L (normal, 3-49); aspartate aminotransferase, 47 IU/L, (normal, 9-37); alkaline phosphatase, 438 IU/L, (normal, 104-338); and g-glutamyl transpeptidase, 168 IU/L (normal, 671). Tumor markers were normal: carcinoembryonic antigen, 2.4 ng/mL (normal, <5.0) and carbohydrate antigen 19-9, 17 U/mL (normal, <37). To evaluate further the abnormal liver enzymes, abdominal ultrasound followed by a contrastenhanced CT of the abdomen was performed (Figure A). Side-viewing endoscope showed duodenal papilla (Figure B). What are the findings of the abdominal CT and side-viewing endoscope and what is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.