A 52-year-old man was admitted to the hospital with severe abdominal pain. He had a history of iron-deficiency anemia for 4 years with no identified cause despite multiple tests. During a recent airline flight, he had sudden abdominal pain after eating almonds that lasted 3 hours and was not relieved by morphine. Examination and initial tests in the hospital were normal. A CT scan showed dilated small bowel with slow transit to the large bowel. He was discharged after his symptoms resolved but returned to the hospital shortly after. Further tests including an enteroclysis were normal. A diagnostic procedure was then performed but unspecified.

1. CASO CIEGO. JUNIO DE 2013. (Dra. García Marín)
A 52-year-old man was admitted to the hospital because of an attack of severe
abdominal pain.
During the preceding four years, the patient had been evaluated repeatedly for chronic
iron-deficiency anemia, but no cause had been identified despite an upper
gastrointestinal endoscopic and colonoscopic examination, a barium-enema study, and
an upper gastrointestinal series with a small-bowel follow-through study. Microscopical
examination of a bone marrow specimen was nondiagnostic. Repeated stool tests for
occult blood were negative. Another, more recent colonoscopic examination was again
negative. The patient's daily medications were ferrous sulfate (500 to 1000 mg), enteric-
coated aspirin (81 mg), and a multivitamin tablet.
One month before admission, while he was on an airline flight, the patient had a sudden
attack of abdominal distention and severe, steady epigastric pain with radiation to the
back. The pain began shortly after he had eaten almonds before a meal, lasted three
hours, and was not affected by two intravenous injections of morphine. He felt febrile
during the episode, but his temperature was not taken. An emergency landing was
made, and a few hours later, when the pain had mostly resolved, the patient was
admitted to another hospital.
Examination revealed a slightly distended, soft, nontender abdomen, with active bowel
sounds. Rectal examination showed no abnormalities; a stool test for occult blood was
negative.
The urine was normal. The hematocrit was 33.1 percent, and the white-cell count was
7900 per cubic millimeter. Bilirubin, electrolyte, and amylase values and the results of
liver-function tests were normal. An electrocardiogram, thoracic radiographs, and an
abdominal ultrasonographic study showed no abnormalities. Abdominal radiographs
revealed a few dilated loops of small bowel, with gas and stool in the rectum. The
patient received intravenous hydration. The results of an esophagogastroduodenoscopic
study, performed on the second hospital day, were normal. A computed tomographic
(CT) scan of the abdomen, obtained after the oral administration of contrast material,
showed dilatation of the small bowel, with slow transit to the large bowel.
The patient was able to tolerate a regular diet, with resumption of bowel function. He
was discharged on the third hospital day, with the recommendation that an enteroscopic
examination or enteroclysis of the small intestine and another colonoscopic study be
performed. The pain did not recur. He came to this hospital shortly after his discharge
from the other hospital.
The patient did not smoke. He drank one or two cups of coffee daily and reported that
he ate a healthy diet, which included nuts. A nonruptured appendix had been excised
when he was 18 years old. Nine months before admission, he had had mild epigastric
pain. A test for Helicobacter pylori antibodies at that time was positive, and a gastric
ulcer was diagnosed without the performance of other tests. He received a two-week
course of four drugs. His mother had had colonic carcinoma in her 80s.
The pulse was 70. The blood pressure was 110/70 mm Hg.
Physical examination showed no abnormalities, and a stool test for occult blood was
negative.

2. Laboratory tests were performed (Table 1 Hematologic Laboratory Values on
Admission. and Table 2. Other Laboratory Values on Admission.). A scan for Meckel's
diverticulum, obtained after the administration of technetium-99m, showed no
abnormalities. The results of enteroclysis, performed with the instillation of barium and
methylcellulose through a nasogastric tube that terminated at the ligament of Treitz,
were normal.
A diagnostic procedure was performed.