Cramplike Pain and Vomiting in a 77-Year-Old Man

James J. McCombie, MB ChB; Erik D. Schraga, MD

Disclosures

March 28, 2017

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case you would like to suggest for a future Case Challenge, please contact us.

Background

A 77-year-old man presents to the emergency department in the early morning with a 4-hour history of severe, generalized abdominal pain. He describes having had some cramplike abdominal pain and bilious vomiting yesterday, but states that he simply "got on with things." His condition had worsened considerably by late evening. He describes the sudden onset of generalized, constant, intense abdominal pain necessitating an ambulance call.

On presentation to the emergency department, the patient has no current vomiting. He describes episodic "indigestion" that has occurred off and on for the past few months. On further questioning, the patient reports experiencing infrequent but quite painful episodes of upper abdominal pain after meals, which sometimes feels as if it is "going to his right upper back" and is associated with intermittent vomiting. This lasts for minutes to hours after the intake of meals. He states that antacid preparations do little good in controlling these symptoms, but he takes them anyway.

His medical history includes hypertension, ischemic heart disease, chronic obstructive pulmonary disease (COPD), and gout. He has no significant surgical history, and his currently prescribed medications include aspirin, atenolol, furosemide, a glyceryl trinitrate spray, and two inhalers for his COPD (the names of which the patient does not know).

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