Aortic intramural hematoma (IMH) is a potentially fatal entity in the spectrum of acute aortic syndrome. It is prone to evolve into aortic dissection, and then followed by aortic rupture, aneurysm or absorption without further sequelae. So, prompt recognition and appropriate intervention are quite essential. However, not all aortic IMH presents typical symptoms, and early diagnosis may be hard and even missed. It is relatively rare for aortic IMH manifesting acute abdominal pain at the begining. In this paper, we reported a 68-year-old man presenting with acute abdominal pain as the early symptom of aortic IMH, which was not recognized immediately, and even misdiagnosed as some abdominal diseases. The disease was identified after radiological examination. Emergency physicians should pay attention to aortic IMH only presenting acute abdominal pain, so as to make early diagnosis and appropriate management.