Patients with acute abdominal pain typically undergo urgent clinical assessment to exclude serious underlying surgical diagnoses. However, a diverse range of less common medical conditions may also present with abdominal pain and their severity can range from benign to life threatening. Here we present a case of myelitis (inflammation of the spinal cord) presenting with acute abdominal pain that was initially diagnosed clinically as biliary pathology. We review the canonical differential diagnosis for medical causes of acute abdominal pain and highlight the clinical features that raise the suspicion of spinal pathology. We argue that awareness of the basic clinical features of structural and inflammatory spinal lesions could improve early recognition of these potentially overlooked diseases.