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JAMA Surgery Clinical Challenge
January 18, 2017

Still Another Case of Right Lower Quadrant Abdominal Pain

Author Affiliations
  • 1Department of Surgical Sciences, University of Insubria, Varese Hospital, Varese, Italy
  • 2Department of Surgery, “C. Ondoli” Hospital of Angera, Varese, Italy
JAMA Surg. Published online January 18, 2017. doi:10.1001/jamasurg.2016.4964

A white man in his early 30s presented to the emergency department with a 48-hour history of exacerbating right lower quadrant and epigastric abdominal pain. Although previously healthy, he reported some hospitalizations for nonspecific abdominal pain during his infancy. Colicky abdominal pain started after eating cornflakes in the morning, then regressed spontaneously during the day. A relapse of the symptoms occurred the morning after and worsened during the day, with the onset of nausea as well. For this reason, the patient autonomously took 2 tablets of hyoscine butyl bromide without any benefit. His bowel was initially open to gas and normal stools but, afterward, only to gas. A physical examination revealed a soft and nondistended abdomen, with localized tenderness and guarding in the epigastric region and in the right lower quadrant. Hyperactive bowel sounds could be heard. The results of a digital rectal examination were normal. His vital signs were as follows: an axillary temperature of 37.3°C, a pulse rate of 71 beats per minute, and blood pressure of 120/80 mm Hg. The results of a urinalysis were negative; blood test results were within the normal limits, except for an elevated white blood cell count of 13 000/μL (to convert to ×109 per liter, multiply by 0.001), an unconjugated bilirubin level of 1.2 mg/dL (to convert to micromoles per liter, multiply by 17.104), an increased aspartate aminotransferase level of 52 U/L (to convert to microkatals per liter, multiply by 0.0167), and an alanine aminotransferase level of 136 U/L (to convert to microkatals per liter, multiply by 0.0167). His C-reactive protein level was 10 mg/L (to convert to nanomoles per liter, multiply by 9.524). A plain radiograph of his abdomen was negative for air-fluid levels and for signs of perforation. Further evaluation of his abdomen using ultrasonography revealed hepatic steatosis and, in the right lower quadrant, thickening of the cecal wall and a hypoechoic area 33 mm in diameter with blurred margins (Figure 1).

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