The Case of the Sickly Scribbler With an Agonizing Belly Ache

The patient was a 59-year-old white male author who complained of severe abdominal pain.

Personal History

The patient was the eldest of 10 children. Two siblings died of typhoid -- one from peritonitis secondary to a perforated intestinal ulcer that had been caused by the disease. His mother died of abdominal cancer at age 44 and his father died at age 82. As an adult, the patient smoked and drank copious amounts of white wine -- often becoming inebriated. He led an irregular life, frequently moving, sometimes eating poorly, and, although he had multiple medical problems, he often failed to comply with medical advice. He had 2 children, a son and a daughter who required frequent hospitalization for attacks of schizophrenia.

Medical History

Throughout adulthood, the patient experienced a number of severe medical conditions. At age 27, he was hospitalized with what was thought to be rheumatic fever, which was followed by attacks of polyarthritis over the course of his life. The patient also suffered from attacks of iritis and glaucoma, which were treated with medications and applications of leeches. He also underwent multiple eye operations. Despite these efforts, his vision gradually deteriorated. In later life, he became blind in his right eye, with limited vision in his left eye. Eventually he could only write using crayons to form large letters, depending on friends to type his manuscripts. Additional health problems included severe dental caries, sciatica, and tonsillitis. Beginning in his twenties, the patient had several attacks of upper abdominal pain, sometimes lasting for a week or more. It was after a final attack that the patient died. Until this last event, his physicians never obtained abdominal x-rays, nor had they succeeded in establishing a definitive diagnosis for the abdominal condition.

Final Illness

His final illness began with "stomach cramps" after an evening meal washed down with copious amounts of white wine. The abdominal pain became so severe that at 4:00 AM the patient called a local physician who administered morphine. Later that day, a surgeon visited the patient and advised hospitalization. The next morning, abdominal x-rays were obtained, and approximately 30 hours after the initial onset of pain, the patient underwent an abdominal operation. For the first several postoperative hours, the patient seemed to be doing well, but he soon weakened. The dLay following surgery, he developed gastrointestinal bleeding and received 2 transfusions. Unfortunately, he soon lapsed into a coma and died on the second postoperative day.^[2] An autopsy was performed.

What is your diagnosis?

1. Intestinal obstruction
2. Ruptured peptic ulcer
3. Ruptured aortic aneurysm
4. Mallory-Weiss syndrome 

 ans: ruptured peptic ulcer

Source:http://www.medscape.com/viewarticle/587838_2