A patient presents with upper abdominal pain radiating to the back and elevated amylase. What is the most likely diagnosis and initial management?

• A. Acute pancreatitis; supportive care with IV fluids, pain control, and evaluation for etiology (gallstones, hypertriglyceridemia)
• B. Acute cholecystitis; antibiotics and cholecystectomy
• C. Peptic ulcer disease; proton pump inhibitors
• D. Esophageal rupture; surgical management

Answer: (A)

Pain in the upper abdomen that radiates to the back with a rise in pancreatic enzymes points to acute pancreatitis. The first steps in management are supportive: give aggressive IV isotonic fluids to restore perfusion, provide adequate pain control, and keep the patient NPO with plans for early refeeding as tolerated. At the same time, look for the underlying cause—gallstones are a common trigger, so arrange a RUQ ultrasound to assess for biliary disease; check triglyceride levels since severe hypertriglyceridemia can provoke pancreatitis; obtain alcohol use history as well. Antibiotics aren’t routinely used unless there’s signs of infection or cholangitis, and surgical intervention isn’t needed initially unless complications develop (such as infected necrosis or gallstone-induced obstruction).