CV, a 71-year-old housewife, with known cholelithiasis and previous myocardial infarction, was admitted to the University of Maryland Hospital in shock, complaining of substernal and high epigastric pain. The admitting diagnosis was coronary thrombosis. Electrocardiographic tracings revealed evidence of an old myocardial infarction with depressed ST segments and inverted T-waves indicative of coronary artery insufficiency. Following resuscitative measures the patient showed signs of abdominal tenderness, with rigidity, ileus and increasing distention. The rapid appearance of bluish flank and periumbilical discoloration and mottling were interpreted as positive Cullen's and Grey Turner's signs. These signs, plus an elevation of serum amylase to 550 Somogyi units prompted a change in diagnosis to acute hemorrhagic pancreatitis. A peritoneal tap performed to substantiate this diagnosis yielded bloody, odorous peritoneal fluid with amylase levels in excess of 7,000 units. The peritoneal fluid ammonia level was 49.9 y/ml. Because of the elevated peritoneal fluid ammonia level a laparotomy was performed. This revealed mesenteric artery thrombosis with irreversible gangrenous changes of the entire small intestine.

This brief clinical summary serves to illustrate the difficulty occasionally encountered in the accurate, differential diagnosis of acute abdominal pain of obscure etiology. The need for early, accurate diagnosis need not be stressed. Some patients, if operated upon needlessly will not tolerate the stress of surgical trauma while others may