Code Status case · Intermediate · Premium
Upper abdominal pain in a 46-year-old man
“It started last night and hasn't let up. It's in my upper abdomen, up under my ribs, and goes straight through to my back.”
“Severe upper abdominal pain since last night. He vomited five or six times and hasn't kept anything down.”
Your challenge
Darius's pain sits high in his belly and goes straight through to his back. It started last night, it has not let up, and he has vomited five or six times. That pattern has a famous cause, but a heart attack, a tear in the aorta, a burst ulcer and an inflamed gallbladder can all present the same way, and the case keeps those doors open on purpose. Once you know what it is, the work turns to fluids, food and finding out why it happened.
After the case, Attending’s Notes explains the decisions that mattered, backed by 10 sources.
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Spoiler: the diagnosis and what this case teaches
Diagnosis
Acute Pancreatitis
Lesson 1
Pain and High Lipase Can Diagnose Pancreatitis
CT is not required when the clinical and enzyme criteria are already met.
- Typical pain + lipase ≥3× normal can diagnose
- Lipase is the enzyme to order, not amylase
- Higher lipase does not mean worse pancreatitis
- Use CT for doubt, poor recovery, or complications
Lesson 2
Look for Gallstones Even With a Drinking History
The cause can change drainage, surgery, and recurrence prevention.
- Gallstones and alcohol cause most cases
- Marked ALT elevation supports gallstones
- First episode: get gallbladder ultrasound
- Triglycerides >1,000 mg/dL suggest the cause
- Cholangitis needs urgent endoscopic drainage
Lesson 3
Replace Fluid Losses and Reassess Frequently
Replace what is missing, then look again.
- Start moderate IV fluids and adjust to the response
- Recheck blood pressure, urine output, and breathing
- Rising BUN or hematocrit warrants fluid reassessment
- Use smaller fluid volumes in cardiac or renal disease
Lesson 4
Resume Oral Feeding Early and Treat the Cause
An improving patient should be eating, not waiting.
- Start oral feeding early in mild disease, as tolerated
- No oral intake if vomiting or unsafe to swallow
- Mild gallstone pancreatitis: surgery this admission
- Organ failure means severe disease, escalate care
- Address alcohol use to reduce recurrence
In the app, every line above opens into the detail behind it: doses, pitfalls and the evidence, with 10 sources linked to the originals.
Darius is a fictional patient. Code Status is for training only and is not intended for real-world patient care, diagnosis, treatment, or clinical decision-making.