An Unusual Case of Abdominal Pain

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A CLINICAL PROBLEM-SOLVING article by Russell Goodman from Brigham and Women's Hospital, Boston.
A 41-year-old man presented to the emergency department with abdominal pain. The pain was excruciating and sudden in onset, originating in his right lower quadrant and radiating to his right groin and flank. It was slightly reduced when he was lying down but was otherwise unaffected by position. He reported nausea and one episode of nonbloody, nonbilious emesis shortly after the onset of the pain. Two weeks before presentation, the patient had had a less severe episode of similar pain but in his left lower quadrant, with radiation to his left flank, which subsequently resolved. He reported that he had had fatigue for several months preceding these episodes.
On physical examination, the patient appeared uncomfortable. Intravenous narcotics were administered.
The initial evaluation of a patient with acute abdominal pain should focus on identifying life-threatening causes and surgical emergencies. This patient's vital signs are reassuring, suggesting the absence of an immediately life-threatening condition, although he has marked hypertension. The history of fatigue may indicate an underlying systemic illness that preceded the episodes of acute pain, but it is nonspecific. The fact that there were two discrete episodes in which the patient had similar symptoms in different distributions suggests an underlying process that is being manifested in different anatomical locations over time.