An Unusual Cause of Recurrent Right Lower Quadrant Pain

A 61-year-old female was hospitalized for a 3-day history of right lower quadrant abdominal pain, described as sharp, non-radiating, worse with movement and associated with nausea and non-bilious, non-bloody vomiting. She also reported a history of right groin pain of 1–2 days duration. She denied diarrhea, constipation, melena, hematochezia, weight change, fevers, or chills. Past medical history included hyperlipidemia, hypothyroidism, and end-stage renal disease due to hypertension and diabetes requiring hemodialysis. Previous surgical operations included an open cholecystectomy and placement of a left upper extremity arteriovenous fistula. Outpatient medications included pioglitazone, metoprolol, amlodipine, furosemide levothyroxine, simvastatin, calcium acetate, aspirin, and occasional use of oral sodium polystyrene sulfonate potassium-binding resin (Kayexalate ). She denied use of tobacco, alcohol or recreational drugs. She had no family history of abdominal malignancy or inflammatory bowel disease. Physical examination revealed an afebrile, normotensive, and mildly hypoxic woman (oxygen saturation of 92 %). A systolic murmur was auscultated at the left sternal border; moderate tenderness to direct palpation was noted in the right lower quadrant and inguinal regions without any rebound or guarding. Complete blood count and liver function tests were normal. Basic metabolic panel: serum sodium 138 mmol/L, potassium 3.9 mmol/L, chloride 94 mmol/L, bicarbonate 31 mmol/L, blood urea nitrogen 20 mg/dL, and creatinine 4.9 mg/dL. Serum calcium, magnesium, and phosphorus were all within normal limits. Due to concern for the presence of an incarcerated hernia, the patient underwent abdominal and pelvic computerized tomographic (CT) scan, which was reported as showing wall thickening of the distal ileum and ascending colon, with pericolic stranding with fat adjacent to the ascending colon, the appendix appearing normal. Bilateral, fat-containing inguinal hernias were also noted. Over the next few days, the patient continued to have abdominal pain, but with improvement in its severity and frequency. Repeat laboratory studies showed elevated white blood cell count of 11.8 9 10, elevated erythrocyte sedimentation rate 46 mm/h, and C-reactive protein 0.6 mg/dL (nl \ 0.3). Stool culture, examination for C. difficile toxin, and fecal leukocytes were negative. During admission, the patient underwent colonoscopy that showed the presence of a 1.5-cm-deep, firm ulcer just distal to the ileocecal valve, with no loss of vascularity of the surrounding mucosa. Biopsies revealed only ulcerated colonic mucosa with architectural distortion. Radiographic follow-through examination of the small bowel was unremarkable. Her symptoms improved, and she was discharged home. An outpatient colonoscopy 1 month later again showed the right colonic ulcer, with grossly normal surrounding mucosa. Biopsies of the terminal ileum and of the ulcer were negative for any specific or definitive findings. Doppler studies of the abdominal vasculature were normal. Given her history of end-stage renal disease, S. Gayle M. Kistin Division of Gastroenterology and Hepatology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA