Visual diagnosis: a 16-year-old female with menstrual cramps and a history of anorexia.

Presentation A 16-year-old African American girl presents to the emergency department with severe cramping and pain in all quadrants of her abdomen, with the most severe pain located in her right upper quadrant. The pain had started 24 hours previously and initially was dull and diffuse. The pain has worsened progressively with sudden, more severe pain developing in the right upper quadrant 5 to 6 hours before she came to the emergency department. She has had three episodes of nonbilious brown emesis over the past 24 hours. Her last bowel movement was 7 days ago, and she denies any blood or mucus in the stool. She reports having mild abdominal cramps over the past week that she attributes to her recent menstrual period; her last spotting was 8 days ago. There is no history of recent fever, diarrhea, or genitourinary problems. She is not sexually active, and there is no history of alcohol or illicit drug use. The patient has occasionally taken a combined medication of acetaminophen, aspirin, and caffeine for her pain. She has no allergies. She is an excellent student, and there are no known psychosocial stressors in the family. The girl has a chronic history of vague abdominal pain while eating, followed by nonbilious, nonbloody emesis and subsequent relief of pain. These episodes of pain started in early childhood and continued until age 12 years. However, her abdominal pain returned at age 14 years; although that pain was severe, there was no emesis. The pain was unrelated to meals but would present sometimes 2 weeks before menses and sometimes during menses. The pain also was associated with occasional inability to pass a stool for a few days. Menarche occurred at age 13 years. For the past 2 years, she thought her abdominal pain was due to her menstrual periods; yet her parents, concerned about a possible eating disorder, brought her to her pediatrician Figure 1. Coronal computed tomography (CT) reformatted image.