A 40-Year-Old Man Comes to the Emergency Department with a Week

question 525

Multiple Choice

A 40-year-old man comes to the emergency department with a week of progressive abdominal discomfort, abdominal distension, and nausea.  Over the last 2 days, he has also had several episodes of vomiting.  Six weeks ago, he was hospitalized for an episode of acute pancreatitis.  The patient used to drink heavily before the hospitalization but has been abstinent since then.  He also has a history of emergency department visits due to alcohol intoxication and street fights.  The patient does not use tobacco or illicit drugs.  His temperature is 37 C (98.6 F) , blood pressure is 117/84 mm Hg, pulse is 86/min, and respirations are 16/min.  Examination shows epigastric fullness and tenderness.  Bowel sounds are present.  There is no rebound tenderness or rigidity.  Cardiopulmonary examination shows no abnormalities.  There is no peripheral edema.  Complete blood count and serum chemistries are within normal limits.  CT scan of the abdomen with intravenous contrast is shown below.  Which of the following is the most appropriate next step in management?

• A)Cholecystectomy
• B)Endoscopic drainage procedure
• C)Intravenous antibiotics
• D)Nothing by mouth and expectant management
• E)Pancreatic enzyme supplementation

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