Clinical case of the month. Expanding abdominal mass in a 41-year-old patient with a history of alcohol abuse.

A 41-year-old man with a history of significant alcohol use presented to an outside hospital with complaints of nausea, vomiting, epigastric pain, and subjective fever for 4 days. He also complained of dizziness and weakness that began 1 day prior to presentation. The patient stated that he drank in excess of one case of beer the night prior to presentation. There was no history of recent trauma. In the past, he experienced sporadic episodes of abdominal pain which lasted for up to 2 days. The episodes were typically preceded by excessive drinking of alcohol. The patient did report a 20-pound weight loss that occurred over the prior 2 years, but denied chest pain, shortness of breath, post-prandial abdominal pain, change in bowel habits, change in stool color, urinary symptoms, or skin abnormalities. The patient has no significant medical history and was not on any prescribed medications. A construction worker, he smoked one-half pack of cigarettes per day for 24 years. He drank beer regularly, sometimes drinking up to one and one-half cases daily. The patient denied intravenous drug use but did admit to smoking cocaine. On presentation, the patient’s vital signs were: temperature of 97° Fahrenheit, pulse rate of 129 beats per minute, respiratory rate of 24 breaths per minute, and blood pressure of 118/56 mmHg. The patient appeared acutely ill and lethargic. Though his speech was slurred, he was oriented in all spheres. Physical exam further revealed temporal wasting, anicteric sclera, and dry mucous membranes. The abdomen was not distended but decreased bowel sounds were appreciated. No tenderness of the abdomen was elicited with palpation, and there was no evidence of a palpable mass or hepatosplenomegaly. Laboratory values on admission were a white count of 14,000/μL (normal range, 4,500-11,000/μL), hematocrit of 47.7% (normal range, 40-51%), platelets of 392,000/μL (normal range, 130,000-400,000/μL), amylase of 349 U/L (normal range, 25-115 U/L), sodium of 149 mmol/L (normal range, 135-146 mmol/L), potassium of 3.5 mmol/L (normal range, 3.6-5.2 mmol/L), chloride of 83 mmol/L (normal range, 96-107 mmol/L) , bicarbonate of 36 mmol/L (normal range, 24-32 mmol/L) , blood urea nitrogen of 86 mg/dL (normal range, 7-25 mg/ dL), creatinine of 6.9 mg/dL (normal range, 0.6-1.2 mg/ dL), glucose of 163 mg/dL (normal range, 70-115 mg/ dL), calcium of 10.0 mg/dL (normal range 8.4-10.3 mg/