CASE
A 69-year-old male presented to the emergency department (ED) with complaints of severe and gradual onset left flank pain of 2 days' duration. A cardiac catheterization with percutaneous coronary intervention had been performed 2 days prior to presentation. The cardiac catheterization revealed an ejection fraction of 60% and normal wall motion, and it also indicated that the patient suffered from three-vessel coronary artery disease (CAD). A bare-metal stent had been placed in the right coronary artery.
The flank pain was localized to the left side, nonradiating, constant, and aching. It was aggravated by activity and relieved by splinting and rest. The patient denied fevers, chills, urinary symptoms, or bowel complaints. His medical history included CAD, degenerative joint disease of the spine, hypertension, irritable bowel syndrome, adrenal neoplasia, and prostate cancer. His surgical history included prostatectomy, hernia repair, appendectomy, and cholecystectomy. The patient had smoked a pipe for 30 years of his life but had not smoked in the past 25 years. He denied any illicit drug use. The patient did not report additional findings on a comprehensive review of systems.
On physical examination, the vital signs were normal. More specifically, integument, pulmonary, cardiovascular, and peripheral vascular findings were all unremarkable. An abdominal examination revealed a protuberant abdomen, active bowel sounds, and tympanic percussion. The remainder of the examination demonstrated tenderness in the left flank but with no costovertebral angle tenderness.
Initial laboratory studies indicated an elevated WBC count (12,100/µL) but no other CBC abnormalities. The basic metabolic panel revealed a BUN of 32 mg/dL, a creatinine of 1.3 mg/dL, and unremarkable electrolytes. An anteroposterior chest radiograph and ECG showed no abnormalities and were unchanged from previous examinations.
The differential diagnosis included nephrolithiasis, splenic rupture, splenic injury, diverticulitis, diverticulosis, and bowel perforation. CT with contrast was ordered (Figure 1). What does the CT scan show?
