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JAMA Surgery Clinical Challenge

Left Lower Quadrant Mass

Image of Figure 1

Figure. Computed tomographic images of the abdomen and pelvis. A, Axial imaging shows that the bladder (black arrow) is displaced to the right, and a Foley catheter is located anteriorly. The rectum (white arrow) is compressed posteriorly. B, Coronal imaging shows that the bladder (arrow) is severely displaced, and a Foley catheter is located medially.

Jan P. Kamiński, MD, MBA
David Ryan, MD
Balasubramaniam Iyer, MD

An 88-year-old man with a history of hypertension, atrial fibrillation while receiving warfarin sodium, congestive heart failure, extended right hemicolectomy for colon cancer, and abdominal aortic aneurysm repair visited the hospital with epigastric pain of 3 days' duration. In addition, the patient had worsening lower back and lower extremity pain, treated as sciatica on an outpatient basis, for 3 months. The patient had constipation, urinary incontinence, and generalized weakness but no fever, nausea or vomiting, or change in bowel movements. Physical examination revealed a firm, nonpulsatile, slightly tender mass in the left lower quadrant and significant perineal ecchymosis. Vital signs were normal. Laboratory test results were remarkable for white blood cell count (13 800/μL [to convert to ×109 per liter, multiply by 0.001]), blood urea nitrogen level (72 mg/dL [to convert to millimoles per liter, multiply by 0.357]), creatinine level (4.2 mg/dL [to convert to micromoles per liter, multiply by 88.4]), hemoglobin level (9.8 g/dL [to convert to grams per liter, multiply by 10.0]), and international normalized ratio (2.7). Computed tomography of the abdomen and pelvis was performed (Figure).

See the full article for an explanation and discussion.

Author Affiliations: Kamiński (jpkaminski@gmail.com), Ryan, and Iyer are affiliated with the Department of Surgery, Illinois Masonic Medical Center, Chicago.