A 28-year-old previously healthy man developed constant mid-epigastric and supraumbilical abdominal pain. One day after the onset of pain, he presented to the emergency department. The patient described his pain intensity as 8 on a scale of 1 to 10. He also described having some nausea but no anorexia, and he experienced a single episode of emesis in the emergency department. He was afebrile, and his heart rate was 86 beats/mi n; blood pressure, 128/86 mm Hg; and body mass index, 28 (calculated as weight in kilograms divided by height in meters squared). Bilateral lower abdominal and supraumbilical tenderness was present, as was lower abdominal voluntary guarding to palpation. Deep palpation of the left lower quadrant did not elicit pain over the right lower quadrant (ie, negative Rovsing sign). Internal and external rotation of the flexed right leg did not elicit pain (ie, negative obturator sign). Dorsif lexion of the right thigh against the examiner's hand resulted in right lower quadrant pain (ie, positive psoas sign). Rectal examination was unrevealing. Levels of liver function enzymes, amylase, and bilirubin were normal, as was a complete blood cell count, except for leukocytosis of 14 000 cells/mm3. Urinalysis was unremarkable. A computed tomography (CT) scaawas obtained (Figure 1).
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