Gastroenterology clinical image challenge: A 61-year-old Asian man with a history of hypertension presented to our emergency department with a two-month history of intermittent, increasing abdominal pain. The patient complained of increasing abdominal discomfort that worsened at night after eating. The pain was vague, nonradiating and unrelated to body position. In the emergency room, the patient’s blood pressure was 193/107 mm Hg and his heart rate was 70 bpm. He was afebrile and physical examination revealed abdominal distension with tympanic percussion sounds and diffuse tenderness without significant rebound tenderness. There were no surgical scars, skin rashes or any identifiable protruding mass evident on the skin. Review of all other body systems was negative. Blood test results, including complete blood count with differential, biochemistry panel and C-reactive protein, were normal except for the presence of mild hypokalemia (3.3 mmol/L).
After analgesics, the patient experienced no improvement in symptoms. Thus, contrast-enhanced computed tomography (CT) scan of the abdomen was ordered (figure), after which an exploratory laparotomy was performed.
What caused the patient’s diffuse abdominal pain?