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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.
Author: Anusuya Mokashi, Medical Student, New York Medical College, Valhalla
Janis A. Pastena, MD, FACS, FACEP, Associate
Professor of Clinical Surgery, New York Medical College
eMedicine Editor: 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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