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A 45-year-old man with a history of gallstones presents in A&E with severe epigastric pain radiating to the back and vomiting.

B Severe epigastric pain radiating to the back is the classic description of acute pancreatitis, and gallstones and alcohol are its two most common causes. Serum amylase is usually significantly raised but this is not specific because amylase can be raised with other conditions that present with an acute abdomen, such as cholecystitis and perforated viscus.