Picture of the Month Quiz
A 13-year-old girl presented with a 2-week history of sharp, intermittent, periumbilical abdominal pain. The pain did not radiate; activity worsened the pain, whereas rest alleviated the pain. The pain was neither worsened by eating nor relieved by defecation. She reported approximately 6 episodes of nonbloody and nonbilious vomiting in these 2 weeks. She reported no change in the frequency or volume of her stools since the onset of abdominal pain, but she did have occasional loose stools. She denied hematochezia but said that occasionally she would feel the need to defecate but could not. She had a 3.15-kg (7-lb) weight loss in the past 3 months. She also described recent onset of malaise and chills. She denied any rash, joint pain, or fever.
On examination, she was afebrile. There was mild tenderness in the right lower abdominal quadrant with no rebound tenderness or guarding. The remainder of her physical examination was normal. Laboratory investigation revealed an elevated erythrocyte sedimentation rate of 37 mm/h (reference range, 0-13 mm/h) and an elevated C-reactive protein level of 3.6 mg/dL (reference range, 0.0-1.0 mg/dL; to convert to nanomoles per liter, multiply by 9.524). Complete blood cell count and basic metabolic profile were unremarkable. An upper gastrointestinal series with barium contrast was performed (Figure 1 and Figure 2).
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