A 61-year-old male with a history of gastroesophageal reflux disease (GERD), hypertension, and diabetes presents to the emergency room complaining of severe abdominal pain. The patient reports epigastric pain on and off for months but with a sudden and severe worsening over the last 8 h. He states that the chronic pain has been a “gnawing” pain that is relieved by eating. He typically takes antacids for relief. He denies smoking, alcohol or nonsteroidal anti-inflammatory drug (NSAID) use. Late last night, the pain suddenly became excruciating, and he is now having trouble moving. On physical exam, blood pressure is 130/70 mmHg, heart rate is 120/min, and temperature is 39.1 °C. He appears to be in severe distress secondary to pain. His mouth appears dry. Bowel sounds are absent. He has diffuse tenderness to palpation, with guarding and rebound tenderness. Laboratory values reveal a white blood cell count of 18,000/μL (normal 4.1–10.9 × 103/μL), blood urea nitrogen (BUN) of 40 mg/dL (7–20 mg/dL), creatinine of 1.8 mg/dL (0.5–1.4 mg/dL), serum amylase of 130 μ/L (30–110 μ/L), and lipase of 60 μ/L (7–60 μ/L). An upright chest x-ray demonstrates free air under the right diaphragm.