Diagnose It Answer — April 21, 2026

46-year-old male presents with severe epigastric pain he describes as 'boring through to my back,' onset 6 hours ago after a large holiday meal and significant alcohol intake. He rates the pain 9/10. He has vomited four times and states vomiting does not relieve the pain. He cannot find a comfortable position and is writhing on the stretcher.

History of alcohol use disorder — drinks approximately 8–10 beers daily, more on weekends. History of hypertriglyceridemia. One prior episode of pancreatitis 2 years ago requiring 3-day hospitalization, also after heavy drinking. No gallstone history. Medications: none current. He denies NSAID or corticosteroid use. BMI 31.

BP 108/68 mmHg, HR 118 bpm, RR 22 breaths/min, Temp 38.2°C, SpO2 95% on room air. Patient is pale, diaphoretic, and appears acutely ill. He is lying in a fetal position — knees drawn toward his chest — which he states slightly reduces the pain.

Abdomen: severe epigastric and periumbilical tenderness on palpation with involuntary guarding. Bowel sounds hypoactive. No rigidity. Cullen's sign (periumbilical ecchymosis) and Grey Turner's sign (flank ecchymosis) absent at this time — their absence does not rule out the diagnosis. RANSONS criteria score calculated at 3 — moderate severity predicted. IV fluid resuscitation started aggressively: Lactated Ringer's 250–500 mL/hr. NPO initiated. Pain managed with IV morphine.

Serum lipase: 2,840 U/L (elevated >3x upper limit of normal; normal <60 U/L — diagnostic threshold). Serum amylase: 980 U/L (elevated). WBC 14,600/µL. Glucose 218 mg/dL. BUN 22 mg/dL, creatinine 1.3 mg/dL. Calcium 7.8 mg/dL (low — saponification in peripancreatic fat). Triglycerides 820 mg/dL (markedly elevated — likely contributing cause). LFTs mildly elevated. CT abdomen/pelvis with contrast: pancreatic edema and peripancreatic fat stranding; no necrosis or abscess at this time.