JAMA Surgery Clinical Challenge
Left Lower Quadrant Mass
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).
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Author Affiliations: Kamiński (firstname.lastname@example.org), Ryan, and Iyer are affiliated with the Department of Surgery, Illinois Masonic Medical Center, Chicago.