Severe Abdominal Pain, Mild Pruritus in a Coffee Drinker

Sarah El-Nakeep, MD


July 05, 2023

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 that you would like to suggest for a future Case Challenge, please contact us.


A 28-year-old woman presents with a 1-week history of severe upper right abdominal pain. The pain is characterized by a feeling of heaviness and radiates to the epigastrium; it increases with coughing or deep breathing but is not associated with meals. Although analgesics partially relieve the pain, it has progressively increased for the past 4 days.

Two days ago, she noticed that her sclerae are slightly yellow. She also has slight itching on her arms, legs, and abdomen. Her urine and stool show no change in color. She has not had any recent bouts of diarrhea or vomiting. No cough or expectoration is associated with her abdominal pain.

The patient smokes and drinks alcohol occasionally but has never used illicit drugs. She drinks large amounts of coffee. She is taking oral contraceptive pills and has regular menses. However, her menses has always been associated with severe pain, for which she takes monthly doses of nonsteroidal anti-inflammatory drugs (NSAIDs). A checkup performed for her gym membership renewal last month revealed no evidence of diabetes, hypertension, chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection, or thyroid hormone dysfunction.


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