This is a 37-year-old female who presented to the emergency room with abdominal pain that was located in the epigastric and left upper quadrant pain for four days. She described the pain as intermittent, ranging from dull to sharp and radiating to the back. She denied any chest pain or radiation of pain to the shoulders. She also had associated nausea and vomiting with worsening intensity after ingesting food. She had never experienced this pain before. Her past medical history included anxiety and depression. She had no other significant past medical history, including any respiratory disorders such as bronchitis. She denied a past surgical history. She did not have a family history of pancreatitis. She was previously prescribed a selective serotonin reuptake inhibitor (SSRI) medication two years ago to help with her anxiety and depression, but she was unable to identify the medication name or dosage. She stopped the medication because smoking medical marijuana controlled her anxiety and depression better, and she did not like the concept of using psychiatric medications. The level of control was significant with medical marijuana, and she described it as being able to perform day-to-day activities without any significant symptoms of anxiety or depression. She had a history of recreational marijuana use since she was a teenager, which improved her anxiety and depression at that time. Her desire to avoid psychiatric medications led her to use medical marijuana currently instead of solely for recreational use.

She denied alcohol use or tobacco use. She reported a consistent pattern of marijuana use, smoking ¼ oz of marijuana two to three times daily over the course of the past 12 months to control her symptoms of anxiety and depression. The exact strain of cannabis was unknown, and if any filter was used during the consumption of marijuana by smoking was unknown. In the emergency room, her vital signs showed a temperature of 98.2°F (36.8°C), a heart rate of 93 beats per minute, a blood pressure of 102/68 mmHg, and a respiration rate of 20 breaths per minute. Her oxygen saturation was 97% on room air. Her BMI was 21.61 kg/m², which is within normal limits. On physical examination, heart sounds were normal S1 and S2, no S3 or S4, lungs were clear to auscultation, and an abdominal exam revealed no abnormalities on inspection. On palpation, there was epigastric and left upper quadrant tenderness. On auscultation, the abdomen revealed hypoactive bowel sounds.

The patient's admission labs are displayed in Table 1. 

Her chest x-ray (CXR) did not reveal any abnormalities. The computed tomography (CT) of the abdomen and pelvis without contrast revealed the normal size of the liver, a normal appearance of the gallbladder, and a mildly enlarged pancreas surrounded by mild fat stranding (Figure 1). The spleen, kidneys, and appendix were within normal limits; sigmoid diverticulosis was present, but there was no evidence of bowel obstruction. The bladder and uterus findings were unremarkable. An ultrasound of the right upper quadrant showed no liver masses or dilated intrahepatic biliary ducts present and no apparent cyst or mass of the pancreas (Figure 2). The gallbladder demonstrated no gallstones or wall thickening, with no sonographic Murphy’s sign (Figure 3). The common bile duct measured 5 mm in diameter (Figure 4). The spleen, kidneys, adrenal glands, and gallbladder were unremarkable. There were no abdominal masses or fluid collection present. Magnetic resonance cholangiopancreatography (MRCP) showed a normal common bile duct of 5 mm and a distended gallbladder with no thickening (Figure 5). 

The patient was admitted for management of acute pancreatitis and treated with lactated ringers 1,000 mL solution intravenous (IV) at 150 mL/hour, ondansetron 4 mg for nausea and vomiting as needed, and toradol 15 mg IV push one time at the initial encounter for pain management. Throughout her admission, she was given morphine 2 mg IV push as needed for pain, acetaminophen 1,000 mg IV every six hours for pain, and ketorolac 10 mg every six hours for pain interchangeably. Her symptoms resolved, and she was discharged two days later with a follow-up with her primary care physician. She was advised to abstain from smoking marijuana.