An 18-year-old girl with a history of migraine headaches, allergic rhinitis, ovarian cysts, and multiple food allergies was referred to the ED with complaints of poorly localized abdominal pain and nausea without vomiting. She had presented to her primary care physician (PCP) earlier in the day with similar complaints and was noted to have decreased bowel sounds and diffuse abdominal tenderness to palpation. At that time, her PCP recommended she proceed to the ED for further evaluation. She had been started on omeprazole one month prior for presumed gastroesophageal reflux disease and endorsed a longstanding history of constipation. In the ED, she complained of two days of intermittent, migratory, cramping abdominal pain associated with diarrhea. Vitals signs were within normal limits. Her exam was notable for tenderness in the epigastrium and RLQ. Gallbladder and appendix ultrasounds (US) were negative for cholelithiasis, cholecystitis, or appendicitis. The patient’s abdominal pain improved over a matter of hours, and she was discharged home with instructions to return to the ED if her symptoms returned. The patient returned to the ED two days later with worsening abdominal pain. It was rated at a 10 of 10 in severity, stabbing in nature, located in the RLQ, with associated nausea and non-bloody, nonbilious vomiting. She was afebrile, tachycardic, and had flushing of the face, neck, and chest. She had an intrauterine device (IUD) and noted two days of bright red vaginal bleeding that she felt was different in quality than her typical menses. She reported having a bowel movement the previous day without blood in the stool, and her diarrhea had resolved. On exam, she had tenderness to palpation in the RLQ and right flank. Physical exam was otherwise unremarkable. Differential diagnosis at this time included gallbladder pathology, such as cholelithiasis or cholecystitis, or appendicitis not seen on initial US, inflammatory bowel disease, irritable bowel syndrome, pancreatitis, urinary tract infection, pyelonephritis, abdominal migraine, or pelvic pathology such as ovarian torsion, ovarian cyst, or ruptured ectopic pregnancy. Initial labs were obtained and included complete blood count, C-reactive protein, hepatic function panel, lipase, coronavirus disease 2019, and urine pregnancy test, all of which were negative or unremarkable. Laboratory studies were notable for a bicarbonate of 18 milliequivalents per liter (mEq/L) (reference range: 23–30 mEq/L) and an anion gap of 16 mEq/L (3–10 mEq/L). Transabdominal and transvaginal pelvic US were negative for ovarian torsion, cysts, or ectopic pregnancy. Her IUD was noted to be in the proper position. Given progression of symptoms and prior unremarkable abdominal US, an abdominal computed tomography (CT) with intravenous (IV) contrast was performed. Abdominal CT demonstrated congenital bowel malrotation with small bowel on the right side and colon on the left side of the abdomen (). The appendix was identified and normal in appearance. There was no evidence of bowel obstruction or active bowel inflammation on CT. All other identified organs, including ovaries, gallbladder, liver, spleen, and kidneys, were normal in appearance. The patient was given IV fluids, morphine for pain control, and ondansetron for nausea. Pediatric surgery was consulted for consideration of surgical intervention. The patient was admitted to the hospital for pain control and brought to the operating room three days after her initial presentation for a laparoscopic Ladd’s procedure given her CT findings of bowel malrotation without alternative diagnosis. Her abdominal pain was thought to be secondary to intermittent volvulus. Intraoperatively, the gallbladder, uterus, and ovaries were normal in appearance. The appendix was grossly normal; however, an appendectomy was performed and sent for pathology. There were few adhesions noted between the right colon and the right abdominal wall. The duodenum had numerous adhesions between the liver and small bowel. She tolerated the procedure without any complications. The patient’s symptoms of abdominal pain and nausea improved postoperatively, and she was discharged to home two days after the procedure. On post-hospital follow-up two weeks after discharge the patient reported complete resolution of gastrointestinal symptoms. Pathology demonstrated an appendix with minimal focal mucosal inflammation and without perforation or fecalith.