A man with radiating loin pain

A 30 year old man presented to the emergency department with severe loin pain. He felt it throughout the right side of his abdomen radiating to the groin, and it was associated with nausea and vomiting clear fluid. The pain “came in waves” but never fully resolved. He had not felt pain like it before and scored it 10/10 in terms of pain severity.

He was usually fit and well and was not taking regular medications. He last ate the previous evening with his wife, who was well, and his bowels were working normally. His history included appendicectomy when he was a child.

Observations showed he was afebrile (36.5°C), tachycardic (pulse rate 110 beats/min), and had normal blood pressure and oxygen saturation readings. On examination he was in pain and found it difficult to lie still. His abdomen was mildly tender on deep palpation of the right flank and iliac