A 46-year-old man comes to the physician because of recurrent abdominal discomfort. He describes episodes of moderate, dull, epigastric pain lasting 2-3 days that have occurred 1-2 times/month over the last 2 years. He also describes occasional nausea but denies any vomiting, diarrhea, black stools, blood in the stool, abdominal distention, or weight loss. He takes ibuprofen for chronic low back pain. He drinks 8-10 beers over the weekends and frequently throughout the week.
His vital signs are within normal limits and his BMI is 28 kg/m². Physical examination is unremarkable.
Fasting blood glucose is 127 mg/dL. Abdominal x-ray shows focal calcifications anterior to the spine over the epigastric area.
Upper GI endoscopy reveals a normal esophagus, gastric varices in the fundus of the stomach, and a normal duodenum.
Which of the following is the most likely diagnosis?

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11ec193a_97fb_7743_853d_b1a3ba7a1869_MD0002_00 This patient's presentation is consistent with chronic pancreatitis due to excessive alcohol intake. Abdominal x-rays typically show calcifications in the area of the pancreas. The splenic vein runs along the posterior surface of the pancreas, where chronic pancreatic inflammation can lead to thrombosis. Splenic vein thrombosis leads to gastric varices near the gastric fundus only; esophageal varices are not seen. Variceal hemorrhage is the most common symptom of splenic vein thrombosis and splenectomy is usually curative. (Choice A) Cirrhosis causes scarring in the liver that leads to increased sinusoidal vascular pressures and portal hypertension. These patients typically present with esophageal varices, diffuse gastric varices (not just gastric fundus), and rectal varices (hemorrhoids). (Choice B) Gastroparesis is usually a complication of diabetes (rather than chronic pancreatitis) and causes delayed gastric emptying. Patients typically present with nausea/vomiting and bloating, and endoscopy will not show varices. (Choice C) Helicobacter pylori is a common cause of ulcer disease and may be associated with dyspepsia. This patient's use of alcohol and NSAIDs increases his risk of peptic ulcer disease, but his endoscopy showing varices make this less likely. (Choice D) Non-ulcer dyspepsia is usually diagnosed after excluding other etiologies (e.g., peptic ulcer disease, GERD, and malignancy). However, this patient's abnormal endoscopy showing varices makes this unlikely. Educational objective: Chronic pancreatitis can lead to splenic vein thrombosis. Gastric varices localized to the gastric fundus confirm the diagnosis. Bleeding from these varices can be cured by splenectomy. __________ References: Splenic vein thrombosis and gastrointestinal bleeding in chronic pancreatitis (http://www.ncbi.nlm.nih.gov/pubmed/14502405) Significance of splenic vein thrombosis in chronic pancreatitis (http://www.ncbi.nlm.nih.gov/pubmed/18585674)

A 46-Year-Old Man Comes to the Physician Because of Recurrent