Beyond the Usual: A Diagnostic Challenge in Abdominal Pain

Abstract

A 36-year-old woman with no prior medical history presented with postprandial epigastric pain associated with early satiety and a 7 kg weight loss over 4 weeks, without improvement on proton pump inhibitors (PPIs). She subsequently developed left flank pain, which prompted her to visit the emergency department. On physical examination, she had tenderness on palpation of the epigastrium and left flank, without guarding or peritoneal signs. She reported symptomatic relief in the left lateral decubitus position. Nutritional assessment showed a risk of malnutrition on subjective global assessment, with a body mass index of 21.8 kg/m². Laboratory tests revealed normal complete blood count, liver enzymes, creatinine, amylase, and lipase; viral serologies for HCV, HBV, and HIV were negative; anti–tissue transglutaminase IgA and anti–deamidated gliadin peptide antibodies were negative. Urinalysis showed no hematuria or proteinuria. An upper gastrointestinal endoscopy was performed and was normal up to the second portion of the duodenum. Gastric and duodenal biopsies were obtained and showed no relevant pathological findings. Given the presence of abdominal pain associated with weight loss and lack of response to PPIs, a contrast-enhanced computed tomography scan of the abdomen and pelvis with oral and intravenous contrast was performed (see images).