Progressive Abdominal Pain

A 46-year-old man with no significant medical history presents to the emergency department with progressive, right-sided abdominal pain that has persisted for 3 days. He states that the pain is constant and worsens with walking or deep breathing. He denies nausea, vomiting, fever, diarrhea, dyspnea, or other complaints.

The patient’s vital signs are normal with the exception of a mild fever of 99.3° F. Lungs are clear to auscultation. The abdomen is soft with right-sided tenderness at McBurney point (two-thirds of the distance between the umbilicus and the right anterior superior iliac spine). Slight guarding without rebound tenderness is noted. Right-sided costovertebral angle (CVA) tenderness is noted. No edema is identified in the lower extremities, and Homan sign is negative. Initial diagnostic concerns include choledocholithiasis, nephrolithiasis, or appendicitis.

Laboratory assessment reveals a white blood cell count of 8.2 cells/µL with 76% polymorphonuclear neutrophils (PMNs). Aspartate aminotransferase and alanine aminotransferase levels are slightly elevated at 83 U/L and 70 U/L, respectively. Urinalysis is negative. Computed tomography (CT) scan is obtained (Figure).