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JAMA Clinical Challenge
July 17, 2020

Abdominal Pain and an Appendiceal Mass

Author Affiliations
  • 1Department of General Surgery, University of California, Los Angeles
JAMA. Published online July 17, 2020. doi:10.1001/jama.2020.4707

A 68-year-old woman with a history of uterine carcinoma (unknown histology) diagnosed and treated 30 years prior with hysterectomy and adjuvant chemotherapy in another country presented with 2 months of generalized abdominal pain and distention. She had no fevers, nausea, vomiting, diarrhea, constipation, blood in the stool, or weight loss. She was not taking any medications. On examination, her temperature was 36.9 °C; heart rate, 72/min; blood pressure, 132/68 mm Hg; and body mass index, 25 (calculated as weight in kilograms divided by height in meters squared). Results of complete blood cell count and serum chemistries were unremarkable, with no leukocytosis and normal differential count. Abdominal examination demonstrated mild distention without fluid wave and mild right lower abdomen and suprapubic tenderness. Computed tomography (Figure 1) and magnetic resonance imaging demonstrated pelvic ascites and an enhancing lesion at the base of the cecum. Two attempts at ultrasound-guided paracentesis were nondiagnostic because of acellular specimens. Serum CA-125 level was normal; carcinoembryonic antigen (CEA) level was 18 ng/mL (reference, <5 ng/mL).