The Challenge: Can you solve a medical mystery involving a healthy 30-year-old man with constant, stabbing abdominal pain?

The Diagnosis column of The New York Times Magazine regularly asks Well readers to take on a difficult case and offer their own solution to a diagnostic riddle. This week, you’ll find a summary of a patient suffering from horrible abdominal pain that sent him to two different hospitals three times in two weeks. We will provide some of the laboratory reports and images ordered by the doctors who originally were faced with this medical mystery.

The first reader to offer the correct diagnosis gets a signed copy of my book “Every Patient Tells a Story” and the satisfaction of solving a case that stumped a roomful of specialists.



The Presenting Problem:

A healthy 30-year-old man develops abdominal pain that worsens dramatically over the course of 48 hours, sending him first to his primary care doctor and then to the emergency room.

The Patient’s Story:

The wife knew that her husband needed to go back to the doctor before he’d even said a word. He’d been wandering restlessly around the house all that day. Standing, sitting, lying down — he was constantly moving, never able to find a comfortable position. When he couldn’t even manage to straighten up completely, and remained hunched over his aching belly, she knew it was time. And so did he. He’d been healthy his entire life. Then, four days ago, he had gotten this strange headache and dense fatigue. Initially he wrote it off — after all, neither he nor his wife had been getting much sleep since his son’s birth five months earlier. But then the belly pain started. It was just below his navel. It was sharp, stabbing, constant — impossible to forget, even for a minute. He went to his primary care doctor, who thought he’d probably picked up a virus, and told him he should feel better in a day or so. But he didn’t. The next afternoon, his wife watched helplessly as her husband paced their apartment restlessly, his torso bent forward as if to put some slack in a taut line that ran through his gut. “You have to go to the emergency room,” she finally insisted. She arranged for her mother to come stay with the baby and drove her husband to the emergency room in their suburban New York town.

The Emergency Room:

The car ride was excruciating. The young man grunted at every bump and change in acceleration. In the E.R., his blood pressure was up; his white count was too. A CT scan suggested he might have an infection in his colon. He was given pain medicine, started on a couple of antibiotics and sent home. But even when he was back in his own bed, the pain never eased — not for a minute. That night, he didn’t sleep at all. The next day, exhausted by the lack of sleep and unrelenting pain, he went back to the emergency room. This time the patient was admitted. All the blood tests ordered were normal, and a second CT scan showed nothing. Puzzled and worried, the local doctors suggested a transfer to Mount Sinai Hospital in New York City. At Mount Sinai the patient had a third CT scan of his abdomen and pelvis. This one showed what might have been a slight thickening of the wall of the rectum.

You can see the CT scan here: Was this colitis? That’s what the first E.R. doctors thought, but he hadn’t seemed to respond to antibiotics, the usual treatment for that problem. And he hadn’t had any diarrhea — an expected sign in patients with an inflamed intestinal tract. The patient was “scoped” by Dr. Ron Palmon, a gastroenterologist, who found no evidence of colitis or any other significant problem.

Exploratory Surgery:

Despite the pretty normal studies, the patient appeared to be in tremendous pain and required very high doses of narcotics to manage it. Concerned that they could be missing something significant, the surgeons took him to the operating room for an exploratory laparoscopy — a procedure where they put a scope into the abdomen to look for the source of the pain. The surgeons removed the patient’s appendix — even though it looked fine — and cut through some adhesions they found from a surgical repair of a hernia done more than a decade earlier. Although the surgeons weren’t convinced that either problem could cause this much pain, they closed him up and crossed their fingers. After the surgery, the patient’s pain seemed a little better, and he was discharged two days later. At home he initially had pain that he and his primary care doctor were happy to attribute to the surgery. He took the Percocet he’d been prescribed and waited to get better. He didn’t. And after being home for five days, it was clear to husband and wife that the stabbing pain was back, and was as bad as it ever was. This time the patient needed no persuasion to return to the hospital. In the E.R., the patient and his wife were greeted by familiar faces. On exam, the young man had no fever, but his blood pressure was very high and his heart was racing. His discomfort was obvious. The plan was to try to control his pain with medications he could take by mouth so that he could go home and follow up with the surgeon the next day. That plan failed, and he was admitted to the hospital again.



The Specialist Exam:

On hearing that the young man was back in the hospital, Dr. Palmon, the gastroenterologist, was intrigued and worried. Most abdominal pain as severe as this patient’s would be diagnosed after this much evaluation. What could cause pain that didn’t cause any lab abnormalities, and couldn’t be seen by CT, colonoscopy or even surgery? Dr. Palmon reintroduced himself to the patient and his wife. The specialist noted that the patient’s blood pressure was very high — and yet both he and his wife were certain that he had no previous history of hypertension. Indeed, he had no serious medical history at all. He’d had a hernia repair as a child and was allergic to aspirin. Otherwise, nothing. He had no medical problems and took no medication. His physical exam was likewise unremarkable. He had the healing surgical scars from the laparoscopic procedure the week before; but his belly was soft and not particularly tender, and he had normal bowel sounds. So why was he in so much pain? Dr. Palmon briefly considered the possibility that the man was faking the pain to obtain narcotics. Certainly he was able to tolerate very high doses of the drugs, which could suggest a patient who abused narcotics and had developed a certain degree of tolerance. Still, it seemed unlikely. The man had no record of drug abuse, didn’t drink or smoke and didn’t appear to be having problems maintaining his law practice. Moreover, patients who are in a lot of pain can also require very high doses of pain medications. So what was the source of the man’s terrible pain? That was the question Dr. Palmon had to answer.



Solving the Mystery:

Now I put that question to you: What could this be? You can read the sigmoidoscopy report, E.R. notes and labs below. If you want additional data, ask for it, and if it is known, I will provide it. I’ll tell you the correct diagnosis on Friday.







Thanks for all your responses! You can read about the correct diagnosis at “Think Like a Doctor: Doubled Over in Pain Solved!”

Rules and Regulations: Post your questions and diagnosis in the Comments section below. The correct answer will appear tomorrow on Well. The winner will be contacted. Select reader comments may also appear in a coming issue of The New York Times Magazine.