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BACKGROUND
A 57-year-old man presents to a local emergency
department with severe abdominal pain after being
evacuated from a cruise ship. The pain, which is most
severe in the right lower portion of his abdomen,
started soon after he boarded the ship 2 days ago. Since
then, the pain has worsened, and the patient has noticed
his abdomen becoming progressively "bloated." The pain
is associated with nausea and vomiting. He has not been
able to have a bowel movement. On further questioning,
the patient reports having night sweats, low-grade
fevers, intermittent abdominal discomfort with
constipation, and a 30-lb weight loss over the last 2-3
months. He has no significant medical history and is not
taking any medications. He does have a significant
family history of colon cancer, soft tissue sarcoma,
pancreatic cancer, chronic myeloid leukemia (CML), and
prostate cancer.
On physical examination, the patient is alert and
oriented. His temperature is 98.8°F, his pulse is 65
beats per minute, his respiratory rate is 18 breaths per
minute, and his blood pressure is 104/67 mm Hg.
Abdominal examination reveals localized tenderness to
palpation in the right lower quadrant (RLQ), with a
palpable mass. He has generalized abdominal distension
but no guarding, rebound, or percussion tenderness.
Rectal examination reveals guaiac-positive, brown stool.
Findings from the respiratory and neurologic portions of
the physical examination are unremarkable.
Laboratory investigations are ordered and reveal a
hemoglobin value of 9.4 g/dL, with a corresponding
hematocrit of 30.8%. His WBC count is 6.2 X 109/L, and
his lactate dehydrogenase (LDH) level is elevated at 285
U/L. Results of an electrolyte panel, liver function
tests, and renal function tests are within normal
limits. Abdominal CT is performed, which demonstrates a
large right lower quadrant mass (see Image). The mass
causes a small-bowel obstruction, and several enlarged
retroperitoneal and mesenteric nodes are noted (not
pictured). What is the likely etiology of this mass, and
what is its treatment? |
Hint
Note the patient's strong family history of
cancer. |
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Authors:
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Anusuya Mokashi, Medical Student, New York Medical College, Valhalla
Janis A. Pastena, MD, FACS, FACEP, Associate Professor of Clinical
Surgery, New York Medical College Eugene Lin, MD, Department of
Radiology, Virginia Mason Medical Center, Seattle, WA, Assistant
Clinical Professor of Radiology University of Washington Medical Center,
Seattle, WA
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eMedicine Editors:
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Eugene Lin, MD, Department of Radiology, Virginia Mason Medical Center,
Seattle, WA, Assistant Clinical Professor of Radiology University of
Washington Medical Center, Seattle, WA
Rick G. Kulkarni, MD, Assistant Professor, Yale School of Medicine,
Section of Emergency Medicine, Department of Surgery, Attending
Physician, Medical Director, Department of Emergency Services, Yale-New
Haven Hospital |
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