Review Question - QID 213710

A 48-year-old man is brought to the emergency room for severe abdominal pain. The patient states that about 5 hours ago he experienced a sharp, 10/10, sudden-onset abdominal pain concentrated at the epigastric region with radiation to the back. He cannot remember any clear precipitating factors including trauma or oral ingestion. He endorses nausea, three episodes of non-bloody, non-bilious emesis, chills, and mild shortness of breath. His past medical history is significant for acute appendicitis status post appendectomy. He admits to drinking 1-2 beers a day; his last alcohol intake was 3 days ago. Family history is significant for myocardial infarction in his father and brother at age 45 and 48, respectively. A physical examination demonstrates epigastric tenderness with some mild guarding. His abdomen is non-rigid and non-distended, and Murphy sign is negative. Skin findings at the extensor surface of the arm are shown in Figure A. What is the most likely etiology of this patient’s symptoms?