Severe mid-epigastric abdominal pain that radiates to the back

Severe mid-epigastric abdominal pain that radiates to the back




Severe mid-epigastric abdominal pain that radiates to the back. The pain improves when the patient leans forward or assumes the fetal position. And worsens with deep inspiration and movement. The patient will also complain of nausea, vomiting, and anorexia, and gives a history of heavy alcoholic intake.


Several etiologic factors have been described for acute pancreatitis, but in 10% to 20% of cases an etiologic factor is idiopathic. The presence of microlithiasis or biliary sludge accounts for 80% of idiopathic pancreatitis. In the US, gallstones followed by alcohol intake are responsible for 80% to 90% of cases of acute pancreatitis. The most common cause worldwide is alcohol consumption (Chatila, Bilal & Guturu, 2019).

Common Differential Diagnosis

Myocardial infarction, hepatitis, cholecystitis, viral gastroenteritis, abdominal aortic aneurysm. Intestinal obstruction, peptic ulcer disease, cholangitis, choledocholithiasis, cholecystitis (Chatila, Bilal & Guturu, 2019).

Diagnostic Work-Up

Abdominal pain is the most common symptom I encounter all the time in the Emergency Department. Together with nausea, vomiting and anorexia. A detailed history is important in narrowing down numerous differentials of abdominal pain. Patients may present with agitation and confusion, and in severe distress. They may give a history of anorexia, nausea. And vomiting with poor oral intake (Chatila, Bilal & Guturu, 2019). The most common presenting symptom is mid-epigastric or left upper quadrant pain that radiates to the back. Sometimes band distribution, often straight through middle back;

Severe mid-epigastric abdominal pain that radiates to the back

many patients describe it as being “stabbed with a knife”, worsens with movement. And is alleviated when assuming the fetal position such as bent over, with spine, hips, and knees flexed. Any patient with an acute abdomen should have a complete blood count with differential and a blood chemistry including renal, liver. And pancreatic function tests. Mild leukocytosis with left shift and elevated hematocrit as a result of dehydration or low hematocrit as a result of hemorrhage can be seen (Chatila, Bilal & Guturu, 2019). Elevated levels of serum lipase or amylase (>3 upper limit of normal) support, but are not pathognomonic for, the diagnosis of acute pancreatitis. Serum lipase and amylase have similar sensitivity and specificity. Early and serial C-reactive protein (CRP) testing is used in acute pancreatitis as an indicator of severity and progression of inflammation (Chatila, Bilal & Guturu, 2019).

MRCP is generally used in patients with renal insufficiency. In hom the use of CT with intravenous contrast is discouraged. CT is the best initial modality for staging acute pancreatitis and detecting complications; however, for serial examinations. MRCP is gaining favor due to better imaging of biliary and pancreatic stones. As well as better characterization of solid versus cystic lesions. ERCP is an endoscopic technique for visualization of the bile and pancreatic ducts and is a sensitive. And specific diagnostic tool in acute pancreatitis. ERCP shows details of the pancreatic ductal anatomy including strictures, rupture. And pseudocysts (Chatila, Bilal & Guturu, 2019).