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JAMA Surgery Clinical Challenge

Right Iliac Fossa Pain

Image of Figure 1

Figure. Abdominal ultrasonographic image revealing a 4.2 × 4.2-cm mass with central echogenicity, the "donut sign" (A). Abdominal computed tomographic scan with oral contrast agent revealing a 8.2 × 4 × 2.6-cm tubular thin-walled filling defect in the cecum and lower part of ascending colon (B). The contrast is seen around, proximal, and distal to the defect, with no obstruction noted.

Mohamed O. Soliman, FRCSI
Emad H. Ayyash, FRCSEd
Ahmad A. Al Mosawi, FRCSI
Sami Asfar, MD, FRCS

A 32-year-old woman presented to the hospital complaining about having colicky abdominal pain for the last 2 weeks. The pain was usually generalized but sometimes radiated to the right iliac fossa. The pain got worse with meals and was associated with nausea but no vomiting. In the last 2 days, the pain was associated with loose stools, but there was no mucus or blood. She had no comorbidities, such as diabetes mellitus or hypertension, and no previous admission to the hospital. She is married and has 4 children; her last child was born 40 days prior to her presentation to the hospital. On examination, her vital signs were normal (temperature, 37.1°C; pulse, 86 beats/min; and blood pressure, 121/86 mm Hg). Her abdomen was soft and lax. There was mild tenderness in the right iliac fossa, but no lump or lumps were felt. Bowel sounds were not exaggerated. Her white blood cell count was 8500/μL (to convert to ×109 per liter, multiply by 0.001), her hemoglobin level was 1.3 g/dL (to convert to grams per liter, multiply by 10.0), and her platelet count was 361 × 103/μL (to convert to ×109 per liter, multiply by 1.0). The results of renal and liver function tests were normal.

Abdominal ultrasonography revealed a 4.2 × 4.2-cm mass in the midabdominal region lateral to the gall bladder fossa. The mass has the “donut sign” with central echogenicity (Figure, A). An abdominal computed tomographic scan (Figure, B) showed an 8.2 × 4 × 2.6-cm tubular thin-walled filling defect in the cecum and lower part of ascending colon. The oral contrast agent can be seen around, proximal, and distal to the defect, with no obstruction noted.

See the full article for an explanation and discussion.

Author Affiliations: Soliman, Ayyash, Al Mosawi, and Asfar (sami@hsc.edu.kw) are affiliated with the Department of Surgery, Mubarak Al-Kabeer Hospital, Kuwait, and Asfar is affiliated with the Department of Surgery, Faculty of Medicine, Kuwait University.