The patient is a 68-year-old man who presented with abdominal pain, nausea and vomiting. He described his pain as 10/10 sharp and mid-epigastric without radiation. He denied any lower gastrointestinal symptoms. Around 2 months previously he had a bout of pancreatitis, but his physicians did not find an etiology.
He had type II diabetes mellitus, hypertension, coronary artery disease (stent), and a known right kidney mass. His medication list included simvastatin, januvia, aspirin, cilostazol, famotidine, actos, lisinopril, plavix, lasix prn and metformin.
Social history was negative for alcohol, tobacco or illegal drugs.
He was afebrile, BP 139/64, heart rate 101, respirations 18. He had mild epigastric tenderness without guarding or rebound. His stool was heme negative and rectal exam showed no tenderness.
Complete blood count showed a slightly elevated WBC – 11. Liver tests:
| Destruction | Obstruction | Factory | |||
| AST | 396 | alk phos | 88 | albumin | 4 |
| ALT | 290 | T. Bili. | 1.3 | INR | n/a |
His lipase was 1056.
RUQ ultrasound showed no stones on this admission as well as his previous admission. The radiologist did note some gallbladder wall thickening.
Consider the differential diagnosis of acute pancreatitis. How would you evaluate the patient further?
