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OpenAthens Shibboleth
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Special Feature
May 2013

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations: Department of Surgery (Dr Kuy), School of Medicine (Dr Vickery), Medical College of Wisconsin; Department of Surgery, Wheaton Franciscan Healthcare (Dr Rosner), Milwaukee, Wisconsin; and Center for Translational Injury Research, Department of Surgery, University of Houston, Houston, Texas (Dr Dua).

JAMA Surg. 2013;148(5):481. doi:10.1001/jamasurg.2013.302a

A 37-year-old woman with a history of cyclic lower abdominal pain and nausea presented to the emergency department with acute-onset right lower quadrant (RLQ) pain and nausea for 1 day, but no fever. Vital signs were normal. Physical examination revealed RLQ tenderness. Laboratory examination included a urinalysis, the result of which was negative, and a white blood cell count, which revealed a mild leukocytosis of 11.6 K/μL. Pelvic ultrasonography was obtained, which showed a right ovarian cyst but without evidence of torsion. Computed tomography (CT) of the abdomen/pelvis was performed, which showed an enlarged, dilated appendix of 11 mm in diameter (Figure 1), which on comparison with a prior CT examination from 5 years prior showed a similarly enlarged, dilated appendix.

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Figure 1. Computed tomography of the abdomen and pelvis.

She underwent a diagnostic laparoscopy, which revealed a hockey-stick shaped appendix, with a dilated, enlarged tip (Figure 2) and a right ovarian cyst. There was no evidence of any powder-burn lesions on the peritoneum or bowel serosa. An appendectomy was performed. Hematoxylin and eosin stains of the enlarged portion of the appendix showed glands and stromal tissue (Figure 3). On follow-up in clinic, her symptoms had resolved.

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Figure 2. Intraoperative image of the appendix.

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Figure 3. Histologic image of the appendiceal specimen with glands and stroma.

What Is the Diagnosis?

A.  Appendicitis

B.  Appendiceal carcinoid

C.  Appendiceal endometriosis

D.  Pelvic inflammatory disease