Please provide an assessment and plan for an adult with chronic abdominal pain, post‑prandial vomiting, early satiety, and heavy intermittent alcohol use (approximately 30 beers every other day).

Assessment and Plan: Chronic Abdominal Pain with Heavy Intermittent Alcohol Use, Post-prandial Vomiting, and Early Satiety

Assessment

This patient's presentation is most consistent with alcohol-related gastroparesis and/or alcoholic hepatitis, with the critical priority being immediate evaluation for life-threatening complications including mesenteric ischemia, alcoholic hepatitis, and impending alcohol withdrawal.

Primary Diagnostic Considerations

Alcohol-Related Gastroparesis (Most Likely)

• The triad of post-prandial vomiting, early satiety, and chronic abdominal pain strongly suggests gastroparesis 1
• Heavy alcohol consumption (30 beers = approximately 420g alcohol every other day, averaging 210g/day) far exceeds the threshold for alcohol-related organ damage 1
• Gastroparesis symptoms—nausea, vomiting, early satiety, and abdominal pain—match this patient's presentation exactly 1, 2

Alcoholic Hepatitis (Must Rule Out)

• This drinking pattern (>210g/day average for likely >6 months) meets diagnostic criteria for alcoholic hepatitis risk 1
• Critical labs needed immediately: AST, ALT, bilirubin, INR 1
• Look for: jaundice, tender hepatomegaly, ascites, encephalopathy 1
• AST/ALT ratio >1.5 with AST >50 IU/mL and bilirubin >3 mg/dL confirms alcoholic hepatitis 1
• If present, 28-day mortality is 12-15% and 84-day mortality is 14-24% 1

Mesenteric Ischemia (Life-Threatening, Must Exclude)

• Heavy alcohol consumption can cause mesenteric vasoconstriction and bowel ischemia 3
• Chronic abdominal pain with food aversion (early satiety, vomiting) is the classic presentation of chronic mesenteric ischemia 1
• Obtain CT angiography of abdomen immediately to evaluate celiac and mesenteric vessels 1

Impending Alcohol Withdrawal/Delirium Tremens (Highest Mortality Risk)

• Peak risk for delirium tremens is 48-72 hours after last drink, with mortality up to 15% if untreated 4
• If patient presents on a "non-drinking day," they are in the highest-risk window 4
• Initiate prophylactic benzodiazepines within first 6-24 hours to prevent progression to delirium tremens 4

Secondary Considerations

Chronic Pancreatitis

• Alcohol consumption >70g/day for >7 years causes chronic pancreatitis 5
• This patient's intake (210g/day average) far exceeds this threshold 5
• Chronic abdominal pain with early satiety and vomiting can indicate pancreatic exocrine insufficiency 6

Gastric Outlet Obstruction or Stricture

• Must exclude mechanical obstruction before diagnosing gastroparesis 1, 2

---

Immediate Workup (Within Hours)

Laboratory Studies

• Complete metabolic panel: AST, ALT, bilirubin, alkaline phosphatase, albumin, glucose 1
• CBC with differential: evaluate for infection, anemia 1
• Coagulation studies: PT/INR (elevated in severe alcoholic hepatitis) 1
• Lipase: evaluate for acute-on-chronic pancreatitis 5
• Blood alcohol level: if >0.08 g/dL, patient is legally intoxicated; if zero, withdrawal risk is highest 4, 7
• Uric acid: if elevated with high-dose pancreatic enzymes planned 8

Imaging

• CT angiography of abdomen with IV contrast:
  • Evaluate mesenteric vessels (celiac, superior mesenteric, inferior mesenteric arteries) for stenosis or occlusion 1
  • Assess for chronic pancreatitis (calcifications, ductal dilation, atrophy) 5
  • Evaluate liver for cirrhosis, ascites 1
  • Exclude mechanical gastric outlet obstruction 1

Alcohol Withdrawal Prophylaxis

• CIWA-Ar protocol with scheduled benzodiazepines (e.g., chlordiazepoxide 50-100mg q6h or lorazepam 2-4mg q6h) 4
• Thiamine 100mg IV/IM daily before any glucose administration 4
• Folate 1mg daily, multivitamin 4
• Monitor vital signs q4h for tachycardia, hypertension, tremor 4

---

Diagnostic Testing (Within 24-72 Hours)

Gastric Emptying Study

• 4-hour scintigraphic gastric emptying study with standardized low-fat egg-white meal is the gold standard for diagnosing gastroparesis 1
• Must verify proper methodology: 4-hour duration (not 2-hour), standardized meal, proper imaging protocol 1
• Delayed emptying confirms gastroparesis; normal emptying suggests functional dyspepsia 1, 2

Upper Endoscopy (EGD)

• Exclude mechanical obstruction: stricture, malignancy, gastric outlet obstruction 1
• Evaluate for: gastritis, peptic ulcer disease, esophageal varices (if cirrhosis suspected) 1
• Perform when patient is hemodynamically stable and withdrawal risk managed 4

---

Management Plan

Alcohol Cessation (Highest Priority for Long-Term Outcomes)

Abstinence is the single most important intervention for this patient's morbidity and mortality.

• When patients with alcoholic chronic pancreatitis stop drinking, abdominal pain disappears in the majority, pancreatic function deteriorates more slowly, and death rate diminishes 5
• Alcohol cessation improves gastroparesis symptoms and prevents progression of liver disease 1, 5
• Refer to addiction medicine or psychiatry for medication-assisted treatment (naltrexone, acamprosate, disulfiram) and counseling 5
• Inpatient detoxification is strongly recommended given this level of consumption and withdrawal risk 4

Gastroparesis Management (If Confirmed)

Dietary Modifications

• Small, frequent meals (6 meals/day) with reduced fat and fiber 1, 6
• Liquid or pureed foods if solid food intolerance persists 1, 6
• Avoid carbonated beverages and alcohol 1

Pharmacologic Treatment for Nausea/Vomiting

• Metoclopramide 5-10mg PO/IV 30 minutes before meals and at bedtime (first-line prokinetic) 1
  • Maximum 12 weeks due to tardive dyskinesia risk 1
• Ondansetron 4-8mg PO/IV q8h PRN for breakthrough nausea 1
• Prochlorperazine 5-10mg PO/IV q6-8h PRN as alternative antiemetic 1

Neuromodulators for Abdominal Pain

• Tricyclic antidepressants (e.g., nortriptyline 10-25mg qHS, titrate to 50-75mg) are first-line for gastroparesis-associated abdominal pain 1
• NEVER use opioids for gastroparesis pain—they worsen gastric emptying and create dependency 1

Advanced Therapies (If Refractory)

• Gastric electrical stimulation (GES): consider if refractory nausea/vomiting after 3-6 months of medical therapy failure and patient is opioid-free 1
• G-POEM (gastric per-oral endoscopic myotomy): consider only at centers of excellence for severe refractory cases with documented severe gastric emptying delay 1

Chronic Pancreatitis Management (If Present)

Pancreatic Enzyme Replacement

• Pancrelipase (CREON) 25,000-75,000 lipase units with each meal and 10,000-25,000 units with snacks 8
• Starting dose: 500-1,000 lipase units/kg/meal for adults with chronic pancreatitis 8
• Take with meals/snacks, swallow whole with adequate liquid 8
• Do not exceed 2,500 lipase units/kg/meal or 10,000 units/kg/day to avoid fibrosing colonopathy 8
• Monitor for: steatorrhea improvement, weight stabilization, abdominal pain reduction 8, 5

Pain Management

• Abstinence is the most effective pain intervention 5
• Tricyclic antidepressants or SNRIs for neuropathic pain component 1
• Avoid opioids due to addiction risk, worsening gastroparesis, and poor long-term outcomes 1

Nutritional Support

Immediate Nutritional Assessment

• Screen for malnutrition: albumin, prealbumin, weight loss percentage 6
• Calorie count and dietary consultation 6

Nutritional Interventions (Stepwise)

1. Oral diet modification: small, frequent, low-fat meals 1, 6
2. Oral nutritional supplements: liquid calories if solid food intolerance 6
3. Enteral nutrition via nasojejunal or jejunostomy tube: if oral intake inadequate after 2-4 weeks 6
4. Parenteral nutrition (TPN): only as last resort for short-term use due to infection and line complication risks 6

---

Critical Pitfalls to Avoid

Alcohol Withdrawal Management

• Do NOT wait for withdrawal symptoms to start benzodiazepines—prophylaxis must begin within 6-24 hours of last drink 4
• Do NOT discharge patient without addressing withdrawal risk—peak DT risk is days 2-5, not day 1 4
• Always give thiamine BEFORE glucose to prevent Wernicke encephalopathy 4

Gastroparesis Management

• Do NOT use opioids for pain—they worsen gastroparesis and create dependency 1
• Do NOT diagnose gastroparesis without proper 4-hour gastric emptying study—2-hour studies are inadequate 1
• Do NOT crush or chew pancreatic enzyme capsules—this destroys enteric coating and causes oral mucosa irritation 8

Mesenteric Ischemia

• Do NOT delay CT angiography if chronic mesenteric ischemia suspected—mortality is high if bowel infarction occurs 1, 3
• Classic triad: postprandial pain, food aversion/weight loss, cardiovascular disease history 1

Alcoholic Hepatitis

• Do NOT miss alcoholic hepatitis—28-day mortality is 12-15% 1
• AST/ALT ratio <1.5 occurs in <2% of biopsy-proven alcoholic hepatitis—if ratio is <1.5, consider alternative diagnosis 1

---

Follow-Up and Monitoring

Short-Term (1-2 Weeks)

• Reassess symptoms: nausea, vomiting, abdominal pain, oral intake 1
• Weight and nutritional status 6
• Liver function tests if alcoholic hepatitis suspected 1
• Alcohol abstinence verification: consider PEth testing (>200 ng/mL indicates heavy drinking) 7

Medium-Term (4-12 Weeks)

• Repeat gastric emptying study if symptoms persist despite treatment 1
• Assess for pancreatic exocrine insufficiency response: steatorrhea, weight, abdominal pain 8, 5
• Addiction medicine follow-up: medication-assisted treatment adherence, counseling 5

Long-Term (3-6 Months)

• Pain reassessment: if pain persists despite abstinence and medical therapy, consider surgical evaluation (lateral pancreaticojejunostomy if ductal dilation present) 5
• Consider advanced gastroparesis therapies (GES, G-POEM) only if refractory to medical management after 3-6 months 1
• Ongoing addiction treatment and relapse prevention 5