Case of the month – what is causing this young man’s abdominal pain?

Continuing our monthly series, Dr Hannah Rosa asks readers to suggest what’s causing abdominal pain in this young man. Put your answers in the comments below.

Your next patient during your morning surgery is a 29-year-old male patient, who is booked in to see you with a 2-week history of abdominal pain. Before calling him in you note that he hasn’t been to see anyone at the surgery for many years, and, other than mild childhood asthma, he has no other conditions listed.

You notice he walks in with ease, seems well enough in himself and appears to have come directly from work, as he is wearing dusty, paint-splattered overalls.

Further questioning reveals that he has been getting crampy abdominal pains, across his whole abdomen, for the last two weeks, and they seem to be getting worse. He has also been experiencing nausea, but no vomiting and his appetite hasn’t been too bad. He has not had loose stools, if anything he has been slightly constipated. He has not had any PR bleeding, no melaena and no slimy stools.

He hasn’t lost any weight, but he has been feeling increasingly tired, with mild headaches, which have prompted him to go to bed earlier in the evenings. He hasn’t had a fever and no one else in his family has been unwell. He doesn’t recall eating anything out of the ordinary and he hasn’t been abroad recently. He has no genitourinary symptoms.

He doesn’t take any medication and hasn’t bought any over-the-counter treatments. He smokes tobacco (10 cigarettes a day) and drinks around 12 units of alcohol a week. There are no relevant conditions that run in his family.

On examination his pulse, blood pressure and temperature are all normal, but he does look slightly pale, and his conjunctiva are paler than expected. He has slight generalised abdominal tenderness, but abdominal examination is otherwise normal. Urine dipstick is also normal.

As he pulls his overalls back on, he asks you whether stress might be causing his symptoms. He explains he is a painter and decorator working to a tight deadline in the renovation of an old Victorian stately home. He has been ‘working all hours’ stripping and sanding paint off the walls, with the paint being around 20 layers thick in places. ‘I’m worried I’m not going to get it done in time, so I’ve been cutting a few corners’, he says.

You doubt that his symptoms are stress-related and have an inkling there may be something unusual going on here. Given his previous rare attendances, the abdominal tenderness and pallor, you feel that there are enough factors to warrant advising him to attend A&E today, as he may need urgent treatment.

When you later review his discharge letter you see that you were right.

What was the cause of his symptoms? What urgent treatment did he need?

Put your suggestions in the comments below! Answer to be revealed soon…

Dr Hannah Rosa is a GP in the North East of England