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Worsening Abdominal Pain in Man With History of Alcohol Abuse

Worsening Abdominal Pain in Man With History of Alcohol Abuse

Forty-eight hours ago, a 39-year-old man presented to the emergency department with emesis and severe upper abdominal pain of semi-acute onset, which radiated slightly to the back. He was admitted and has been managed conservatively with intravenous fluids, analgesics, and nothing to eat or drink.

In the past several hours, however, his condition has significantly deteriorated. He has assumed a fetal position but still seems unable to get comfortable. He now complains of thirst, is quite agitated, and is becoming confused.


The patient has had similar episodes in the past and was told they resulted from pancreatic inflammation. He has a long history of alcohol abuse and had been drinking at least half a bottle of vodka daily during the week before his admission. He also had been hospitalized previously for heart failure and atrial fibrillation that were thought to be alcohol-related.


Temperature is 38.3°C (101°F ); heart rate, 150 beats per minute; and respiration rate, 20 breaths per minute. The mucosae are dry, but there is no scleral icterus. Chest is clear. Bowel sounds are markedly diminished, and the abdomen is diffusely tender, with the greatest tenderness in the upper mid-epigastrium; rebound tenderness is noted as well.


Hematocrit is 50% (on admission, it was 39%); leukocyte count is 19,000/µL (on admission, 16,700/µL), with 11% band forms; and platelet count is 91,000/µL (on admission, 171,000/µL). Blood glucose level is 253 mg/dL, which is essentially unchanged from the level on admission. Serum amylase and lipase levels are both significantly elevated at 906 U/L and 2011 U/L, respectively. Lactate dehydrogenase level is 510 U/L. The C-reactive protein level in a sample obtained the morning after admission is 191 mg/dL.

The admission CT scan revealed significant streaking and necrosis of the pancreas and a single small fluid collection near the tail. Abdominal ultrasonography shows no gallstones or dilation of the bile ducts.

Which of the following would be least beneficial for the patient at this time?

A. Transfer the patient to an ICU for fluid resuscitation and monitoring.
B. Empirically initiate broad-spectrum antibiotics.
C. Arrange for immediate surgical debridement of necrotic pancreatic tissue.
D. Provide nutritional support if necessary—enteral if possible, or total


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