Hyperemesis and Epigastric Pain in......
zkadhem - 06-14-09 17:33

A 27-year-old man presents to the emergency department (ED) with a 2-day history of hyperemesis followed by episodes of hematemesis. He complains of worsening epigastric pain, diarrhea, and myalgia. The patient also describes experiencing night sweats and rigors. No melena or hematochezia is reported. He admits to being a "binge drinker" and having consumed approximately 21 cans of beer 3 days ago. The patient's relevant past medical history includes esophagitis, which was diagnosed last year and was treated with a long-term proton pump inhibitor. He has no known drug allergies and has not taken any other medications recently. He does not admit to using any illegal substances. He has a significant family history of hypertrophic obstructive cardiomyopathy (HOCM). He works as a laborer and has smoked 10 cigarettes a day for the past 6 years. Soon after presenting in the ED, the patient collapses.

On physical examination, he has a temperature of 99.5°F (37.5°C). He is in sinus tachycardia, with a heart rate of 130 bpm, and his blood pressure is noted to be 118/82 mm Hg. On examination, the patient is severely dehydrated and agitated, with tenderness to palpation noted in the upper chest and neck. The lungs are clear to auscultation, and heart sounds S1 and S2 are heard, with no murmurs or added sounds. His abdomen is soft, with a tender epigastrium.

The initial work-up includes laboratory investigations; the clinically significant results report a raised white blood cell (WBC) count of 17.9 × 103/µL (17.9 x 109/L; normal range, 4-11 x 103/µL), sodium of 147 mEq/L (147 mmol/L; normal range, 135-145 mEq/L), potassium of 2.6 mEq/L (2.6 mmol/L; normal range, 3.5-5.0 mEq/L), blood urea nitrogen of 14.5 mg/dL (5.2 mmol/L; normal range, 7-19 mg/dL), and creatinine of 1.71 mg/dL (151 µmol/L; normal range, 0.8-1.7 mg/dL). Liver function test results are slightly deranged, with the main abnormality being a raised γ-glutamyltransferase (GGT) of 716 units/L (normal range, 11-51 units/L). An electrocardiogram (ECG) is performed and shows a prolonged QT interval, with ST depression in the inferior and anterolateral leads. The patient is diagnosed with multi-organ failure caused by sepsis, and he is transferred to the high dependency unit (HDU). The patient is treated with vigorous fluid resuscitation and broad-spectrum intravenous (IV) antibiotics. Further probing of the history reveals that he has vomited 30 times in the past 24 hours.

An erect posteroanterior chest radiograph is urgently obtained (see Figure 1). An abnormality on the chest radiograph prompts a computed tomography (CT) scan of the chest (see Figure 2) and the abdomen.
What is the underlying etiology?