Clinical Challenge: Recurrent Abdominal Pain

History of Present Illness

A man in his mid-20s presents to the emergency department (ED) with a 2-day history of left upper quadrant and epigastric abdominal pain associated with vomiting. The patient reports no fever, diarrhea, or other symptoms. He has had similar symptoms multiple times in the past but no health care provider has ever made a definitive diagnosis. No blood or coffee-ground material is found in the vomitus and he denies use of marijuana, excessive alcohol, or nonsteroidal anti-inflammatory drugs (NSAIDs).

Vital Signs and Physical Examination

The patient’s vital signs are normal except for an elevated pulse of 115 beats per minute. All laboratory studies are normal. Physical examination is normal except for tachycardia, left upper quadrant pain, and epigastric tenderness and guarding. No costovertebral angle (CVA) tenderness is found and a genitourinary examination is unremarkable. A computed tomography (CT) scan is ordered (Figure).