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Thursday, June 2, 2016

The Case with an Unusual Cause


The patient was a 38-year-old man with a past medical history of alcohol use and abuse. His last drink was the day before presentation. He reported that he normally drinks daily, but couldn't drink that day because of nausea, vomiting, and epigastric pain.

PMH: None

PSH: None

PFH: None

Social History: Occasional marijuana

ETOH: ~12 beers a day, no IV drug abuse

Vitals: HR: 122 bpm; BP: 110/60 mm Hg; temp: 99.0°F; Pulse ox: 99%; RR: 20 bpm

General: Mild distress from pain

HEENT: WNL, nonicteric, poor dentition

Neck: WNL

CV: Tachycardia, no murmurs

Resp: CTA

Abd: Soft, tender epigastric

Ext: WNL


What do you see?

Yep, pancreatitis.

A whole host of things cause pancreatitis, ranging from idiopathic, also known as unknown, to more common causes like alcohol use/abuse, trauma, and medications (sulfa, NSAID, tetracycline). There always seems to be that one resident who answers scorpion stings, and in this case, he would be right. Where most of us work, alcohol, omnipresent in our society, will usually be the cause.

The diagnosis can be made in one of three ways: history alone, radiography, or an elevated lipase/amylase level. Patients usually have a known history of pancreatitis from an offending agent, and taking away the offending agent (alcohol) alleviates the pancreatitis.

The main goal of treatment is to rest the pancreas and treat the underlying cause, hydrate, and control pain. Most patients get admitted, but a few select patients with minor disease can be treated as outpatients with close follow-up.

Dr. Goldstein is a clinical assistant professor of emergency medicine, the director of tactical medicine, and the director of the physician support unit for EMS and disaster medicine at Einstein Healthcare Network in Philadelphia. Read his blog, Visual Diagnosis in the ED, at, and follow him on Twitter @erdocsg.