Severe Epigastric Abdominal Pain

Abstract

A 56-year-old male with a history of gastroesophageal reflux disease (GERD), hypertension, and diabetes presents to the emergency room complaining of severe abdominal pain. The patient reports epigastric pain for months, but it has just acutely become intolerable over the last 8 h. He states that the chronic pain has been a “gnawing” pain that comes on after eating. He thought he was just having some indigestion and would take some antacids for relief. Late last night, the pain became excruciating and now he is having trouble moving. At initial exam, blood pressure is 130/70 mmHg, heart rate is 110 bpm, and temperature is 101.5 °F. He appears to be in severe distress secondary to pain. The patient refuses to straighten his legs because it hurts too much. He almost jumps off of the table when you press on his abdomen. He has diffuse guarding and rebound tenderness. Blood work is drawn displaying a WBC of 15,000/μL (normal 4.1–10.9 × 10³/μL), BUN of 35 (7–20 mg/dL), creatinine of 1.8 mg/dL (0.5–1.4 mg/dL), serum amylase of 70 μ/L (30–110 μ/L), and lipase of 60 μ/L (7–60 u/L). An upright CXR demonstrates free air under the right diaphragm.