A 55-year-old man presented to the emergency department with flu-like symptoms of several days' duration and right lower abdominal pain for 1 day. On examination, he was afebrile but tenderness was elicited at McBurney's point together with slight rebound tenderness. The white blood cell count was 15,200 (normal, 4500-11,000) with 80% polymorphonuclear cells; urinalysis found 7 white cells per high-power field. Abdominal CT suggested the possibility of a mass in the cecum with inflammatory changes. The patient was hospitalized, was given nothing by mouth, and treatment with intravenous fluids and an antibiotic was begun. During the first hospital day he continued to have right lower quadrant pain, and diarrhea developed. Because inflammatory bowel disease was considered in the differential diagnosis, colonoscopy was performed and disclosed a mildly inflamed, erythematous cecum (A); pus was exuding from an edematous appendiceal orifice. No other abnormalities were noted. At laparotomy, the appendix was markedly inflamed and had perforated. The patient recovered fully and was discharged on the sixth hospital day.
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