VIII-3. A 47-year-old woman presents to the emergency room with severe mid-abdominal pain radiating to her back. The pain began acutely and is sharp. She denies cramping or flatulence. She has had two episodes of emesis of bilious material since the pain began, but this has not lessened the pain. She currently rates the pain as a 10 out of 10 and feels the pain is worse in the supine position. For the past few months, she has had intermittent episodes of right upper and mid-epigastric
pain that occur after eating but subside over a few
hours. These are associated with a feeling of excess gas. She denies any history of alcohol abuse. She has no medical history of hypertension or hyperlipidemia. On physical examination, she is writhing in distress and slightly diaphoretic. Vital signs are: hear rate 127 beats/min, blood pressure 92/50 mmHg, respiratory rate 20 breaths/min, temperature 37.9°C, SaO2 88% on room air. Her body mass index is 29 kg/ m2. The cardiovascular examination reveals a regular tachycardia. The chest examination shows dullness to percussion at bilateral bases with a few scattered crackles. On abdominal examination, bowel sounds are hypoactive. There is no rash or bruising evident
on inspection of the abdomen. There is voluntary
guarding on palpation. The pain with palpation is
greatest in the periumbilical and epigastric area without rebound tenderness. There is no evidence of jaundice, and the liver span is about 10 cm to percussion. Amylase level is 750 IU/L, and lipase level is 1129 IU/L. Other laboratory values include: aspartate amino transferase (AST) 168 U/L, alanine aminotransferase (ALT) 196 U/L, total bilirubin 2.3 mg/dL, alkaline phosphatase level 268 U/L, lactate dehydrogenase LDH 300 U/L, and creatinine 1.9 mg/dL. The hematocrit is 43%, and white blood cell (WBC) count is 11,500/μL with 89% neutrophils. An arterial blood gas shows a pH of 7.32, PaCO2 32 mmHg, and a PaO2 of 56 mmHg. An ultrasound confirms a dilated common bile duct with evidence of pancreatitis manifested as an edematous and enlarged pancreatitis. A CT scan shows no evidence of necrosis. After 3 L of normal saline,
her blood pressure comes up to 110/60 mmHg
with a heart rate of 105 beats/min. Which of the following statements best describes the pathophysiology of this disease?