Peer Reviewed

Pain Management

A 38-Year-Old Man With Severe Abdominal Pain

    Ronald N. Rubin, MD1,2 Series Editor

    1Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
    2Department of Medicine, Temple University Hospital, Philadelphia, Pennsylvania

    Rubin RN. A 38-year-old man with severe abdominal pain. Consultant. 2021;61(11):e25-e28. doi:10.25270/con.2021.11.00003

    The author reports no relevant financial relationships.

    Ronald N. Rubin, MD, Temple University Hospital, 3401 N Broad Street, Philadelphia, PA 19140 (


    A 38-year-old man presents with several days of ongoing severe abdominal pain in his upper abdomen that radiates to his back. He describes the pain as “boring and unrelenting” and is not crampy or colicky.

    History. There is little he can do to ameliorate the pain, although he has found that lying on his side with his legs flexed is least uncomfortable for him. He in unable to keep down any foods or liquids since onset because of increased pain when he tries and emesis. The latter had onset a day or so after the pain started and has been unrelenting with 5 to 10 episodes per day.

    When questioned, he relates similar pain but of much milder nature several times in the last year or two, which would resolve in a day or two when he “babied his stomach” with clear liquids only. He related no other symptoms and has not been febrile.

    His medical history is noncontributory. His only medications are occasional acetaminophen and ibuprofen for minor muscle and joint symptoms. He works for a landscaper. When he was younger, he sporadically used illicit drugs but has been sober for many years. He is and has been a heavy drinker since he was a teenager, with particularly heavy alcohol intake—both liquor and beer—on weekends.

    Physical examination. He is non-icteric but manifests profound dehydration with parched mucosae, has tachycardia with a heart rate of 108 beats/min at rest, and has a blood pressure of 95/60 mm Hg supine. There are no spider telangiectasias or ascites.

    The only significant finding was a quiet abdomen with significant guarding but no rigidity. There is exquisite tenderness to any direct palpation to his mid- and upper epigastrium with radiation to his back. There was no tremor or fasciculation of the tongue, and he was oriented to place, person, and time.

    Diagnostic testing. Results of STAT basic laboratory testing showed profound hypovolemia with a blood sodium level of 132 mEq/L (reference range, 135-145 mEq/L), creatinine level of 2.1 mg/dL, and a blood urea nitrogen level of 40 mg/dL (reference range, 6-24 mg/dL). His hemoglobin level was 15 g/dL (reference range, 13.5-17.5 g/dL), a white blood cell count of 17,000/μL (reference range, 5000-10,000/μL), and serum lipase level of 670 U/L (reference range, < 160 U/L). An abdominal ultrasound was negative for gallstones and otherwise noncontributory.

    After 6 hours of aggressive fluid resuscitation using Ringer’s lactate solution, there was improvement in the patient’s volume status and metabolic panel values, such that he could safely undergo a thin-slice abdominal computed tomography scan. Results of which demonstrated severe peripancreatic stranding with small areas of pancreatic hypoperfusion (necrosis) and several small areas of fluid collection.



    Answer and discussion on next page.


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