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Upper Abdominal Pain, No Relief from Pepto-Bismol: Seen in the ED


A man in his mid-sixties reports constant bilateral chest pain that radiates to the back that began yesterday. Can you Dx based on the CT image here?

Upper Abdominal Pain, No Relief from Pepto-Bismol: Seen in the ED image credit D Brady Pregerson, MD
Brady Pregerson, MD

History of present illness. A man in his mid-sixties with a history of endoscopy-confirmed gastroesophageal reflux disease (GERD) and esophagitis presents to the emergency department with epigastric/chest pain. He reports constant bilateral chest pain radiating to the back since the day before. He denies any aggravating factors, shortness of breath, nausea, or vomiting. He took Pepto-Bismol with minimal relief.

Vital signs & physical examination. Vital signs are normal except for elevated blood pressure (190/115 mm Hg). Other than mild epigastric tenderness, the physical examination is otherwise unremarkable.

Initial diagnostic testing

CBC: normal

CRP: 2.4

Blood chemistry: bilirubin 1.3/0.4 mg/dL, ALT/AST 120/60 U/L

Imaging: see CT below

What is the most likely diagnosis?

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