A 55-year-old woman had eight months of upper abdominal pain. Proton-pump inhibitors had been changed more than once. Ultrasound showed no gallstones and no obvious mass.
The pain was cramping and predictable. She had lost weight because she had begun avoiding larger meals.
The clue hidden in the history
The pain consistently began about 20–30 minutes after eating and gradually settled later.
The reproducible post-prandial pattern and food avoidance prompted vascular evaluation. Chronic mesenteric ischemia was identified.
The diagnostic twist
Abdominal pain is often approached by location. In this case, timing and physiology were more revealing: food increases intestinal blood-flow demand, exposing an inadequate vascular supply.
Clinical pearls
- Ask when pain starts relative to meals.
- Unintentional weight loss plus food fear deserves careful evaluation.
- Failure of reasonable acid-suppression therapy should trigger diagnostic reconsideration.
Take-home message
Sometimes the most important abdominal finding is on the clock, not on palpation.
Educational note: This is a fictionalized/composite teaching case created for clinical reasoning. It is not a record of an identifiable patient and is not a substitute for local protocols, specialist advice or patient-specific clinical judgement.