Picture quiz When vomiting relieves severe abdominal pain
A 72 year old woman presented with sudden onset of severe epigastric and left upper quadrant pain. The pain was sharp and constant, relieved only by vomiting. The vomitus was projectile and streaked with blood. Medical history included a hiatus hernia, for which the patient was taking a proton pump inhibitor.
On admission, the patient looked unwell. She was pale, tachycardic, hypotensive (86/50 mm Hg), and oliguric. Abdominal examination revealed a grossly distended, tympanic abdomen that was diffusely tender, most markedly across the upper abdomen. Urine analysis was normal. Blood tests showed a moderately raised white cell count (14.1×109/l) and C reactive protein (11 mg/l). The amylase level was normal. Arterial blood sampling showed a metabolic acidosis with a base excess of −8.4. It was noted that a nasogastric tube was difficult to pass.
This patient had chest radiography (figs 1 and 2) and subsequent computed tomography (figs 3 and 4).