A 12-year-old girl presents to the emergency department with a 5-hour history of abdominal pain, nausea, and vomiting. The pain is periumbilical, radiating to the left lower quadrant, colicky, and rated 5/10 at the onset. In the emergency department, she rates the pain as 8/10 and has two nonbloody, nonbilious episodes of emesis. She denies any fever, constipation, or diarrhea. She is not sexually active, had menarche 2 months ago, and had her last menstrual period end 3 days ago. She denies dysmenorrhea. She has no allergies, hospitalizations, or previous surgeries.

On physical examination, the patient is in severe distress, afebrile, and pale. Mucous membranes are moist, and the girl has hyperpigmented perioral and intraoral mucosal lesions, freckles on her face, and macules on the tips of the fingers. Her abdomen is soft, nondistended, and tender to palpation on bilateral lower quadrants with rebound tenderness. No masses are palpable and...

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