a 33-year-old man with abdominal pain

a 33-year-old man presented to the emergency department ed) with complaint of 2-day history of abdominal pain. his pain developed with gradual onset prominently in epigastric area after eating dried mushrooms. the pain was diffuse, persistent, radiating to the back and aggravated by meal. he had been tolerating only liquids and had complaints of nausea and vomiting. he had no history of diabetes mellitus, hypertension, alcohol consumption, malignancy, or prior surgery. on arrival his blood pressure was 128/72 mmhg, with a heart rate of 101 beats/minute and a respiratory rate of 20 breaths/minute. he was afebrile. physical examination revealed diffuse abdominal distention, hyper-pitched bowel sounds, and tenderness more marked over the umbilicus with no guarding or rebound tenderness. a complete blood cell count showed the following: leukocyte count 12600 /mm 3 ; segmented neutrophils 90%; hemoglobin level of 14 mg/dl; hematocrit 30%; and platelet 420000/µl. other laboratory studies included: glucose 101 mg/dl; serum urea nitrogen 45 mg/dl; serum creatinine 2.0 mg/dl; sodium 148 meq/l; potassium 3.1 meq/l; serum glutamic oxaloacetic transaminase (sgot) 38 u/l and lipase 30 u/l. figure 1 shows patient’s plain upright abdominal x-ray as well as coronal and axial cuts of abdominal ct scan.