JAMA Surgery Clinical Challenge
Right Lower Quadrant Pain
Figure. Ultrasonographic image of the right lower quadrant (A) and sagittal reformatted computed tomographic image (B), both showing a thickened wall outpouching (arrow) arising from the vermiform appendix (arrowheads) with inflammatory changes in the surrounding mesenteric fat (asterisk). C, Gross findings of excised appendix (arrowheads) reveal an inflamed wall outpouching (arrow) and mesenteric fat (asterisk).
Pierre Lemercier, MD
Lucía Flors, MD
Silvia Paz Maya, MD
Omar Andrés Carreño Saenz, MD
Carlos Leiva-Salinas, MD
A 50-year-old man presented to the emergency department with a 4-day history of right lower quadrant pain that did not migrate during that period of time. On examination, he tested positive for the Blumberg sign. Blood analysis showed leucocytosis, neutrophilia, and an increased level of C-reactive protein. Ultrasonographic (Figure, A) and computed tomographic images (Figure, B) showed a thickened wall outpouching arising from a discreetly thickened appendix and inflamed surrounding fat. Right-sided colonic diverticulosis was also seen. The patient underwent an appendectomy with gross findings as shown in Figure, C.
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Author Affiliations: Lemercier, Flors (firstname.lastname@example.org), and Leiva-Salinas are affiliated with the Department of Radiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain, Paz Maya is affiliated with the Department of Radiology, Hospital Clínico Universitario, Valencia, Spain, and Carreño Saenz is affiliated with the Department of Surgery, Hospital Universitario y Politécnico la Fe, Valencia, Spain.