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JAMA Surgery Clinical Challenge
June 2014

Abdominal Pain and Mass

Author Affiliations
  • 3is a medical student at University of Virginia, Charlottesville
  • 1Department of Surgery, University of Virginia, Charlottesville
  • 2Department of Pathology, University of Virginia, Charlottesville
JAMA Surg. 2014;149(6):613-614. doi:10.1001/jamasurg.2013.1694

A 28-year-old man presented with several months of constant, burning upper abdominal pain centered on the epigastrium. The pain was associated with morning nausea and was worsened by food and alcohol. He was given trials of proton pump inhibitors and dicyclomine with no relief. He had no prior chronic medical conditions. His family history was positive for a brother with kidney stones. He was a former smoker but denied current drug or alcohol use. Review of systems was positive for dry throat, gastroesophageal reflux, and frequent headaches. Physical examination was notable for a faintly palpable midabdominal mass slightly to the left and above the umbilicus with localized discomfort to palpation. Ultrasonography of the abdomen showed a hypoechoic, hypervascular, solid mass left of the midline (Figure, A). A subsequent computed tomography scan of the abdomen and pelvis demonstrated a left adrenal myelolipoma and a 4.4 × 3.7-cm hypervascular soft tissue mass just left of the midline within the mesentery in close approximation with the small bowel, centered at the level of the L3-L4 intervertebral disc (Figure, B). A laparotomy was performed and a round, well-circumscribed soft tissue mass located approximately 90 cm distal to the ligament of Treitz at the base of the mesentery was removed intact without the need for bowel resection (Figure, C). Pathologic photomicrograph of the specimen is shown (Figure, D).

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