A 50-year-old, male North African immigrant presented with 3 hours of abdominal pain, initially diffuse, then migrating to the lower abdomen, with greater right-sided pain. He had nausea and anorexia but no fevers and no abnormal bowel movements. He had been admitted a month prior with several days of abdominal pain, vomiting, and melena. At that time, esophagogastroduodenoscopy revealed nonbleeding duodenal varices and abdominal ultrasonography was within normal limits. He was discharged home with treatment for Helicobacter pyloriand scheduled for a capsule study but was lost to follow-up.
On initial examination on this visit, vital signs were within normal limits. The abdomen was mildly obese and distended, with diffuse voluntary guarding and rebound tenderness that was greatest in the right lower quadrant. Rovsing sign was positive. Laboratory analysis revealed leukocytosis with a leukocyte level of 14 900/μL (to convert to ×109per liter, multiply by 0.001) and a hematocrit value of 35.4% (to convert to a proportion of 1.0, multiply by 0.01). Abdominal computed tomography with oral and intravenous contrast revealed fat stranding and free fluid around a mildly thick-walled appendix. There was also a 4.8 × 3.8-cm mass with possible ulceration involving the small bowel in the right lower quadrant (Figure 1). There was no intraperitoneal free air or lymphadenopathy.
Abdominal computed tomography demonstrating a right lower quadrant mass appearing to involve the small bowel, with oral contrast opacifying an adjacent loop of small bowel.
A. Perforated appendicitis
B. Mediterranean intestinal lymphoma
C. Gastrointestinal stromal tumor
D. Jejunal adenocarcinoma
Lord C, Ozgediz D, Cohen MJ. Image of the Month. Arch Surg. 2009;144(1):87. doi:10.1001/archsurg.2008.533-a