A 42-year-old man, engineer presents to the Emergency Department (ED) in our hospital with severe upper abdominal pain that awakes patient up, intermittent over the past 10 days, but the pain has acutely worsened today, now radiating throughout the patient's upper abdomen and to his back.
The pain increases on laying flat on his back and slightly improves when on sitting upright.
The patient has mild nausea without vomiting. He has no change in his bowel habit. Also he has no chest pain, shortness of breath, or palpitations.
He has no chronic medical conditions and denies using any medications including nonsteroidal anti-inflammatory drugs (NSAIDs).
He was smoker and drink some glasses of bear daily.
On physical examination, the patient is noted to be a thin, slightly emaciated man.
His vital signs include a temperature of 35.6°C, a pulse of 87 beats/min, a respiratory rate of 28 breaths/min, a blood pressure of 110/60 mmHg, and an oxygen saturation of 98% while breathing room air.
He is sweaty and wiggles. No jaundice or cyanosis. The oropharynx is clear, with slightly dry mucous membranes. The heart examination reveals a regular rhythm, with no murmurs.
The lungs are clear to auscultation in all fields, and no rales or rhonchi are found. The abdominal examination showed severe tenderness in the epigastric and bilateral upper quadrant regions, with focal rebound tenderness and guarding.
No tenderness or palpable masses are found in the patient's lower abdomen. The rectal examination reveals heme-negative, brown stool.
The patient is urgently placed on a cardiac monitor. The patient is given 2 doses of IV morphine, without significant improvement of pain or tenderness.
An upright, anterior/posterior chest radiograph is obtained, and sowed no air visualized under the diaphragm. An abdominal ultrasonography was normal.
All laboratory investigations, including a complete blood count (CBC), random blood sugar, urea & creatinine, liver function tests, serum amylase and lipase, and troponin, are within normal limits. An electrocardiogram (ECG) revealed a normal sinus rhythm at a ventricular rate of 88 beat/min, with nonspecific ST flattening in the lateral leads without any change from his prior ECG.
After the initial workup is completed, an additional dose of IV pain relief drug is administered to the patient, which provides some improve of the pain (although focal epigastric tenderness persists).
The computed tomography (CT) scan of the abdomen and pelvis with oral and IV contrast images are obtained (see Figures 1 and 2).
1- What is the cause of the patient's acute abdominal pain?
2- What is the clue for the diagnosis?
3- In Such case, Pnatoprazole – if been indicated – for how many hours per day, it would maintains the gastric pH more than 3 ?