87.A 50-year-old man presents to the ED complaining of abrupt onset of
epigastric pain that radiates to his back. He describes the pain as constant
and associated with nausea and vomiting. The pain improves mildly if he
leans forward. He has a 20-pack-year smoking history and has consumed
6 packs of beer daily for more than 5 years. His BP is 150/80 mm Hg, HR
is 98 beats per minute, temperature is 100.1°F, and his RR is 18 breaths per
minute. He is tender to palpation in the epigastric area. A chest x-ray
reveals a small left-sided pleural effusion. His WBC count is 12,000/μL,
hematocrit 39%, plasma glucose 225 mg/dL, AST and ALT are within nor-
mal limits, alkaline phosphatase 96 U/L, and lipase 520 U/L. His CT scan
is seen below. What is the most likely diagnosis?
84 Emergency Medicine
a. Abdominal aortic aneurysm
b. Mesenteric ischemia
c. Pancreatitis
d. Bowel perforation
e. Cholecystitis