Abdominal pain is a common presentation in the emergency department, and constipation is one of the commonest causes in elderly patients. We report a patient with a ruptured abdominal aortic aneurysm (AAA) who presented with features mimicking acute bowel obstruction. The abdominal radiograph, which showed a calcium rim sign, raised the suspicion of AAA. It was confirmed with contrast-enhanced computed tomography, which showed a large ruptured AAA. The patient was transferred immediately to a vascular center for urgent endovascular repair of AAA and made a complete recovery. This case highlighted the usefulness of plain abdominal radiography in diagnosing abdominal pain, which should not be taken for granted as it can aid in raising concerns of AAA. This case sends an important message, particularly to junior doctors, that symptoms of abdominal pain, vomiting, and total constipation can mask the possibility of AAA. Immediate treatment of a ruptured aortic aneurysm requires a high index of clinical suspicion.
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