Severe Epigastric Pain with Nausea and Vomiting

A 41-year-old woman presents to the emergency department complaining of severe and continuous epigastric pain for the past 24 hours. The pain radiates straight through to her back. She has had progressive nausea with vomiting. The vomit is bile-stained and without blood. She has had similar but less severe episodes of abdominal pain in the past, usually after eating heavy meals, but they always resolved within a few hours. She is gravida two and para two, with last menses 2 weeks ago, and does not consume any alcohol. On exam, she is afebrile, heart rate is 115 beats/min, blood pressure of 128/86 mmHg, and respiratory rate is 18/min. Her abdomen is not distended. She has no surgical scars on her abdomen and no obvious masses visible. She has no bruising around her umbilicus or along her flank. Bowel sounds are hypoactive. She has marked tenderness to palpation in her epigastrium, without guarding or rebound. The remainder of her abdomen is soft and non-tender to palpation. No masses or organomegaly are appreciated. Laboratory examination reveals a white blood cell count of 17.2 × 10(3)cells/μL (normal 4.1–10.9 × 10(3) cells/uL), amylase of 1545 u/L (30–110 u/L), lipase of 1134 u/L (7–60 u/L), ALT of 245 u/L (7–56 u/L), AST of 263 u/L (5–35 u/L), serum glucose of 156 mg/dl (65–110 mg/dL), and LDH 180 u/L (0–250 u/L). An abdominal series demonstrates gas throughout the small and large bowel and a focal dilated loop of proximal small bowel without air fluid levels. There is no free air under the diaphragm.