For most patients who come in for evaluation of abdominal pain, an x-ray rarely elucidates the etiology of the pain, with a couple of rare exceptions:
1. An 18-yr-old male accompanied by his mother is here for a one week history of vague symptoms: intermittent nausea and vomiting, generalized achy abdominal pain, no fever. It was difficult to get much detail from the patient, who was quite taciturn. [A preceptor that I worked with in medical school would often compare trying to elicit information from sullen adolescents to "veterinary medicine"]. The physical exam was not particularly remarkable; there was no abdomen rigidity or rebound tenderness. Imagine my surprise when the abdominal x-ray revealed a developing small bowel obstruction with air-fluid levels. Why would a previously healthy teenager with no surgical history develop SBO? Turns out he had a perforated appendicitis that was confirmed only by exploratory laparotomy.
2. A 38-yr-old man comes in for evaluation of sudden left-sided sharp abdominal pain that started at 4:00 am. I've learned to take it very seriously when people recall the exact time that a specific pain started. This man looked uncomfortable but was oddly dismissive of his pain, initially declining an abdominal x-ray. I am very glad that I finally talked him into it, because what showed up on the imaging was free air under the diaphragm which I had only read about but had never seen in real life. By this time, he had become tachycardic with a systolic blood pressure in the 80s, and he was promptly shipped off to the ED. The surgeon who took him to the OR found the source of the free air to be a perforated diverticulitis, remarking in the operative report: "This was the most pristine bowel I had ever seen". Five points to Gryffindor for having such a clean colon!
