Lower Quadrant Mass Research Articles

Right lower quadrant mass in a geriatric patient.

An 88-year old man presented at the geriatric outpatient clinic with fatigue and weakness since three weeks. One month before presentation, he was admitted with erysipelas of the left lower leg. After discharge, he progressively developed loss of appetite and fatigue. The day before presentation, he noticed a painless swollen lump in his right lower quadrant (Figure 1A). His medical history consisted of a transient ischemic attack, osteopenia, polymyalgia rheumatica treated with steroids, appendicular abscess treated with antibiotics and percutaneous drainage six years before, gallstones, chronic kidney disease, iron deficiency anemia and diverticulosis. Laboratory findings showed an elevated CRP (191.0mg/dL [≤ 5.0mg/dL]) and mildly elevated liver function tests. A computed tomography scan was performed and showed a large abdominal mass

Appendiceal Mucinous Adenocarcinoma with Concurrent Tuberculous Appendix: An Unusual Overlap of Two Rare Diseases

Background: Primary tumors of the appendix are rare and present with symptoms of acute appendicitis or a palpable right lower quadrant mass. The appendix is also an uncommon site of granulomatous tuberculosis infection for gastrointestinal extra pulmonary disease. This case report highlights an unusual overlap of the two diseases and a brief review of literature.

Conservative Treatment of Spontaneous Rectus Sheath Hematomas: Single Center Experience and Literature Review.

Introduction Spontaneous rectus sheath hematoma (SRSH) is characterized by bleeding within the rectus abdominis muscle sheath, one of the rare causes of acute abdominal pain. Early diagnosis is imperative in SRSH to prevent complications and the treatment is usually conservative. We intended to present in this study our experience with SRSH patients with respect to diagnostic evaluation and management of their disease. Materials and Methods In this retrospective study, 14 patients who had received treatment for SRSH in our clinic between January 2012 and December 2017 were assessed in terms of demographic and clinical characteristics, comorbidities, laboratory parameters, diagnostic approach methods, treatment practices, length of hospital stay, and patient outcomes. Results The patients consisted of 10 (71.4%) females and 4 males (28.6%). The age of the patients ranged between 47 and 93 with a mean age of 66.5 ± 12.1. Anticoagulant treatments were being administered to 5 (35.7%) patients, antiplatelet treatments to 4 (28.5%) patients, and both anticoagulant and antiplatelet treatments to 4 (28.5%) patients. The most common triggering factor was severe cough and the most common initial symptom acute abdominal pain (71.4%). In physical examinations, the entire patients had generalized abdominal tenderness, 10 (71.4%) voluntary guarding and 7 (50%) a right lower quadrant mass. The diagnosis was confirmed by abdominal ultrasonography and computed tomography. Based on the computed tomography findings, the disease was classified as Type 2 found in 9 (64.3%) patients, Type 1 in 3 (21.4%) patients, and Type 3 in 2 (14.2%) patients. All the patients were treated conservatively. They were hospitalized for 1 to 23 days. There was no mortality. All the patients were followed up between 3 months and 2 years and no recurrence was recorded. Conclusion Considering the presence of SRSH particularly in older female patients who use anticoagulant drugs and have newly developed an abdominal pain and a palpable mass after coughing spells is the key to make an early and correct diagnosis and to prevent possible morbidity and mortality with an appropriate treatment method.

V7-10 ROBOT-ASSISTED LAPAROSCOPIC NEPHROURETERECTOMY OF A RIGHT PELVIC KIDNEY IN A PEDIATRIC PATIENT

You have accessJournal of UrologyPediatrics1 Apr 2016V7-10 ROBOT-ASSISTED LAPAROSCOPIC NEPHROURETERECTOMY OF A RIGHT PELVIC KIDNEY IN A PEDIATRIC PATIENT Michael V. Hollis, Patricia S. Cho, Evalynn Vasquez, David A. Diamond, and Richard N. Yu Michael V. HollisMichael V. Hollis More articles by this author , Patricia S. ChoPatricia S. Cho More articles by this author , Evalynn VasquezEvalynn Vasquez More articles by this author , David A. DiamondDavid A. Diamond More articles by this author , and Richard N. YuRichard N. Yu More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.567AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Pelvic kidney occurs due to failure of the kidney to ascend normally from the pelvis during development. The condition is typically asymptomatic, but many patients are prone to ureteropelvic junction (UPJ) obstruction due to malposition or malrotation. Complications of pelvic kidney include infections, stones, and renal failure. Enhanced visualization and greater dexterity are needed to locate and to control anomalous blood vessels. Added difficulty is encountered in patients with adhesive disease from previous abdominal surgery such as those with a VP shunt. The robotic approach allows for better access to and for delicacy with deep pelvic structures. We aim to demonstrate the application and safety of a robotic approach to the pelvic kidney nephroureterectomy in the pediatric population. METHODS A 4 year old (16 kg) male with a history of hydrocephalus with VP shunt reported recurrent abdominal pain and emesis, and a right lower quadrant mass was noted on physical exam. Ultrasound demonstrated a right pelvic kidney with moderate hydronephrosis of the upper and lower pole moieties. MAG-3 nuclear medicine scan findings were difficult to interpret due to poor renal function. A DMSA scan revealed a split differential function of 8% on the right side, indicating severely impaired renal function. The patient underwent a robot-assisted laparoscopic nephroureterectomy of a right pelvic kidney. RESULTS The right pelvic kidney was removed without perioperative complications. Pathology revealed hydroureteronephrosis, marked glomerulosclerosis, and tubular hypertrophy/atrophy with chronic interstitial nephritis. Ultrasound at 6 weeks post-op demonstrated normal compensatory hypertrophy of the left kidney and an unremarkable right lower quadrant absent of fluid collections. CONCLUSIONS Nephroureterectomy of a pelvic kidney is challenging due to anomalous renal vessels. The robotic approach allows for excellent visualization and for dissection of deep pelvic structures. Robotic nephroureterectomy of a pelvic kidney is feasible and successful in the pediatric population, and the presence of a VP shunt does not preclude this procedure. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e725 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Michael V. Hollis More articles by this author Patricia S. Cho More articles by this author Evalynn Vasquez More articles by this author David A. Diamond More articles by this author Richard N. Yu More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Appendiceal Adenocarcinoma Masquerading as an Ovarian Mass: A Case Report

Introduction: Primary appendiceal carcinomas are rare neoplasms of the gastrointestinal tract that have seen an increase in diagnosis over the past 10 years. The most common presentation is acute appendicitis or abdominal distension, although occasionally they may present as an adnexal mass due to their anatomical location. We present a case report of the diagnosis of an appendiceal adenocarcinoma found on colonoscopy that presented as a gynecological neoplasm. Case: A 77 year old female was referred to the office from gynecological oncology for evaluation an 8cm x 7cm right pelvic mass seen on CT scan. The CT was ordered due to complaints of several months of weakness, 30lb weight loss, and intermittent localized right lower quadrant abdominal pain. The mass was extensive and was causing deviation of her bladder and severe right-sided hydroureter. A colonoscopy done about 10 years ago was normal. History was significant for right-sided breast cancer status post right radical mastectomy, total abdominal hysterectomy, and 25 pack year history of smoking. Her family history was positive for esophageal cancer in her mother, but denied breast, ovarian, gastric, and colon cancers. Her vitals were within normal limits. Her abdominal exam was significant for tenderness to palpation in the right lower quadrant with fullness. On pelvic exam, there was a large, non-tender, fixed right-sided adnexal mass. Lab studies revealed CEA = 416.2; CA-125 = 11; and CA 19-9 = 1. A colonoscopy was performed prior to her planned surgical resection. Initial observation was unremarkable, including examination of the distal terminal ileum. The markedly elevated CEA level and location of the lesion warranted more aggressive investigation, and the appendiceal orifice was gently probed with a closed cold forceps. This revealed a large friable, appendiceal mass which was biopsied. The biospies revealed adenocarcinoma, with markers suggesting colon over ovarian etiology. An attempt was made to resect the tumor, but due to the extent of the disease and co-morbidities, this was not done and a palliative bypass was performed. Discussion: In this case, based on the right lower quadrant/pelvic mass, ovarian and colonic tumors were considered. On colonoscopy, care was given to search for tumors, particularly inside the appendiceal orifice. With a known elevated CEA in a patient with a right lower quadrant mass, a diagnosis of appendiceal adenocarcinoma was able to be made preoperatively on colonoscopy. Diagnosis of appendiceal adenocarcinoma is rarely made on colonoscopy and is often found incidentally on appendectomy.

Rectus sheath hematoma: an unfortunate consequence of novel anticoagulants.

A 76-year-old male presented to the emergency department complaining of intense abdominal pain. He reported one week earlier an upper respiratory illness with violent coughing spells. Past medical history included recent percutaneous coronary intervention for a myocardial infarction 6 months prior where he received three drug-eluting stents and was subsequently discharged home on Prasugrel (Effient) and Aspirin. Physical exam revealed a large tender right lower quadrant mass with areas of ecchymosis appreciated over the supra-pubic and right lower abdominal region. Abdomen was otherwise soft and non-distended. Basic laboratory tests were noted to be within normal limits. A computed tomography (CT) of the abdomen and pelvis was performed and revealed a 12cm rectus sheath hematoma in the right lower quadrant (Figures 1 and ​and22). Figure 1 Axial view computed tomographic scan revealing hematoma within the rectus sheath (arrow). Figure 2 Coronal view computed tomographic scan revealing hematoma within the rectus sheath (arrow). DIAGNOSIS Rectus sheath hematomas (RSH) are often misdiagnosed and overlooked as a cause of acute abdominal pain. It has been estimated that RSH account for 1.5–2% of unexplained abdominal pain in hospitalized patients,1 but with the widespread use of newer agent anticoagulants this number is likely on the rise. RSH result from the accumulation of blood in the rectus sheath, secondary to disruption of the blood vessels that course through it. The most common inciting factors are direct trauma, strenuous straining (e.g. coughing, exercise, vomiting), and anticoagulants.2 Large hematomas are more likely to occur in patients who have disruption of one of the epigastric arteries in combination with anticoagulant use. The mortality rates associated with RSH can be as high 25% for those patients on anticoagulation drugs3 and is due to a delay in diagnosis as symptoms are often non-specific. Not all patients will have a visible hematoma on physical exam at time of presentation, often leading to further delays in diagnosis. The diagnostic modality of choice is CT of the abdomen and pelvis, which is believed to be 100% sensitive4 for RSH. Management of RSH is dependent on the grade of hematoma that encompasses the size, degree of anti-coagulation, and the patient’s hemodynamic status. Low-grade RSH can usually be managed with conservative treatment. Higher-grade hematomas require more aggressive treatment including blood products, reversal of anticoagulation, and in certain cases surgical evacuation.2,5 Our patient was treated conservatively with Desmopressin and was discharged without additional complications.

Appendiceal Torsion Presenting as a Right Lower Quadrant Mass

Appendiceal Torsion Presenting as a Right Lower Quadrant Mass

Left Lower Quadrant Mass

Left Lower Quadrant Mass

Woman with Right Lower Quadrant Mass and Abdominal Pain

220 were within normal limits, except for a heart rate of 119 beats/min. Physical examination elicited tenderness to palpation in the right lower quadrant with guarding. There was an absence of referred pain or rebound tenderness. Laboratory studies were significant for a white blood cell count of 19.2/mL. An ED bedside ultrasound of the right lower quadrant revealed a complex mass with a nonuniform pattern of internal echoes. The appendix could not be visualized. A formal transvaginal ultrasound confirmed the presence of a complex cystic mass

Extraosseous Ewing sarcoma with foci of neuroblastoma-like differentiation associated with EWSR1(Ewing sarcoma breakpoint region 1)/FLI1 translocation without prior chemotherapy

Peripheral primitive neuroectodermal tumor/Ewing sarcoma and neuroblastoma are distinct malignant tumors belonging to the group of undifferentiated solid pediatric tumors. We report a case of a 14-year-old adolescent girl who presented with a right lower quadrant mass. At surgery, a mobile retroperitoneal mass was entirely removed. Histologic evaluation revealed 2 distinct components; the first, consisting of sheets of undifferentiated cells, was CD99+ and CD56-, whereas the second, consisting of multiple foci of neuropil and maturing neuroblasts, was CD99- and CD56+. Fluorescence in situ hybridization analysis revealed the presence of EWSR1/FLI1 translocation in both histologic distinct components. MYCN (myelocytomatosis viral related oncogene, neuroblastoma derived) was not amplified. The tests for t(11;22) and t(21;22) performed by reverse transcription-polymerase chain reaction were negative. The final diagnosis corresponds to an extraosseous Ewing sarcoma with foci of neuroblastoma-like differentiation. This is the first case, documented by molecular studies, in which neuroblastoma-like differentiation has been noted in primitive neuroectodermal tumor/Ewing sarcoma without prior chemotherapy.

Ileocecal collision tumor composed of adenocarcinoma and primary malignant lymphoma.

Collision tumor means that two kinds of histologically distinct tumors coexist and neighbor without histological interminglement. This report describes a rare case of an ileocecal collision tumor composed of adenocarcinoma and primary malignant lymphoma. A 76-year-old woman was referred to our institute with anemia and a right lower quadrant mass. Colonoscopy revealed type 2 advanced colon cancer in the cecum accompanied by a submucosal mound neighboring this cancer, which appeared different from the usual shape of colon cancer. A barium enema study manifested the typical apple-core sign in the cecum with a smooth semicircular line appearing in the shadow of the apple-core sign. Biopsy specimens showed adenocarcinoma, so a right hemicolectomy was performed. The gross resected specimen presented a mass measuring 64×58×28mm at the ileocecal portion. The half of this mass on the colonic side had a crater-like appearance, whereas the remaining part of the mass on the ileal side had an aspect with a smooth surface. Microscopic examination disclosed that the mass was composed of adenocarcinoma and malignant lymphoma bordering on each other and mediated by a thin layer of connective tissue. Cases of colon tumors with an unusual epithelial and submucosal appearance may be instances of collision tumors composed of cancer and malignant lymphoma.

Extra scrotal spermatocele causing lower abdominal pain: a first case report

Lower quadrant abdominal pain is a common complaint evaluated in emergency departments (EDs). The number of differential diagnoses is lowered when the pain in a male patient is associated with a palpable tender mass. These diagnoses include inguinal hernia, inflamed inguinal lymph node, rectus sheath hematoma, cryptorchidism, mass derived from the spermatic cord, and polyorchidism. We report a case of extra scrotal spermatocele causing lower quadrant abdominal pain that was misdiagnosed as an inguinal hernia on several ED visits. Lower quadrant mass and pain caused by a spermatocele are unusual conditions. Upon the patient's third (ED) visit, the painful mass remained located in his right lower quadrant. The lower quadrant mass was movable on palpation and with pressure could be delivered into the superior aspect of the scrotum. The patient had an abdominal and pelvic computed tomography scan and lower quadrant ultrasound. The imaging studies revealed the mass to be a cystic structure. Surgical excision confirmed that the mass was a spermatocele. Differential diagnoses, diagnostic approaches, and treatment are discussed.

Heterotopic gastric mucosa leading to recurrent intussusceptions: Report of a case

Although most cases of intussusception during childhood are caused by viral enlargement of the Peyer's patches, the remainder of the cases may be due to congenital anomalies, such as heterotopic gastric mucosa (HGM). This report presents a case of HGM in a 4-year-old boy. The patient presented with acute abdominal signs with a right lower quadrant mass. His medical history indicated three episodes of recurrent intussusceptions. The abdominal ultrasound examination detected an intussusception. A laparotomy revealed an ileocolic intussusception and reduction was accomplished. During exploration, an intraluminal mass in the ileum, which was the lead point, was discovered by palpation. An enterotomy showed a 2-cm-diameter crater-shaped mucosal thickening. An ileal resection and anastomosis was performed. The histopathological examination revealed HGM. Heterotopic gastric mucosa is supposed to be of vitellointestinal tract origin and may cause intussusception as being a lead point in the ileum. Despite its rarity, HGM should be considered in cases of recurrent intussusceptions and diagnostic studies should be performed. A laparotomy is required for the diagnosis and treatment in complicated cases. Surgical management should include reduction of the intussusception and careful manual examination of the ileum which may expose such pathology. An intestinal resection and anastomosis is sufficient to prevent complications.

Appendicular mass imitating a malignant cecal tumor on f18-FDG PET/CT study: a case report

Fluoro-Deoxy-Glucose Positron Emission Tomography/Computerized Tomography scan is a very useful method in the diagnosis and follow-up of gastrointestinal malignancies, although it may cause confusion in differential diagnosis.We present a 48-year-old man admitted with a right lower quadrant mass. Upon an unyielding colonoscopy due to inability to pass beyond the hepatic flexure, a Fluoro-Deoxy-Glucose Positron Emission Tomography/Computerized Tomography strongly suggested a right colonic or cecal malignancy. Eventual laparatomy revealed a periappendiceal plastron due to appendicitis that was subsequently proven histological diagnosis.Although Fluoro-Deoxy-Glucose Positron Emission Tomography/Computerized Tomography is a reliable diagnostic tool for colonic malignancies, it can misdiagnose such masses due to inflammatory process around the cecum.

Volvulus of an Appendiceal Mucocele: Report of a Case

Few cases of volvulus of an appendiceal mucocele have been reported. The mechanism of torsion seems to be similar to that suggested for ovarian or appendegeal torsion, where a solid organ or mass fixed onto a narrow stalk is a precondition. We report the case of a young woman who presented with signs and symptoms of acute appendicitis. Computed tomography showed a cystic mass of fluid consistency in the right lower quadrant. An emergency laparoscopy revealed a 720 degrees torsion of a gangrenous mucocele around the proximal part of the appendix. We performed a laparoscopic appendectomy and she recovered uneventfully. The presentation of volvulus of an appendiceal mucocele can mimic other common conditions. Prompt surgical intervention is essential to prevent gangrene and perforation. The combination of a cystic, right lower quadrant mass, and clinical findings suggestive of acute appendicitis should alert the clinician to include volvulus of an appendiceal mucocele in the differential diagnosis.

Primary appendiceal cancer: Gynecologic manifestations and treatment options

To determine the presenting symptoms, gynecologic manifestations, and optimal intraoperative management of women with primary appendiceal cancer. A multi-institutional investigation was performed to identify female patients with primary appendiceal cancer who were treated from 1990 to present. Forty-eight women with primary appendiceal cancer were identified from the tumor registries of participating institutions. The most common symptoms were abdominal pain (40%) and bloating (23%), but only 8% experienced rectal bleeding. Serum CEA was elevated (>2.5 U/ml) in 67% of patients, and serum Ca-125 was elevated (>35 U/ml) in 50% of patients. Thirty-one patients (65%) presented with a right adnexal or right lower quadrant mass and were operated on initially by a gynecologic oncologist. Ovarian involvement by metastatic appendiceal cancer was documented in 18 patients (38%). All of these patients underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and staging, but only 8 had a right hemicolectomy at the time of initial surgery. Forty-one patients (85%) presented with advanced stage appendiceal cancer (Stage III or IV) and 19 patients (46%) received postoperative chemotherapy, most commonly with a combination of 5-FU/Leukovorin. Following surgery, 22 patients (46%) experienced disease progression or recurrence, and 14 have died of disease. The most common sites of recurrence were abdominal or pelvic peritoneum (18), colon (2), and ovary (2). Patient survival was 70% at 2 years, and 60% at 5 years. Women with primary appendiceal cancer frequently present with ovarian metastases, and initial surgical intervention is often performed by a gynecologic oncologist. All patients with mucinous epithelial ovarian cancer should undergo appendectomy at the time of surgical staging. The appendix should be examined intraoperatively, and if appendiceal carcinoma is identified, a right hemicolectomy and appropriate surgical staging should be considered.

Preoperative Multidetector Computed Tomography Diagnosis of a Seminoma Originating from an Undescended Testis by "Testicular Vascular Pedicle" Sign

We report a 65-year-old man with a palpable right lower quadrant mass who underwent multidetector computed tomography (MDCT) examination. Preoperative diagnosis of seminoma was possible by demonstration of "testicular vascular pedicle" sign by MDCT. We describe CT findings of the "testicular vascular pedicle" sign in this report.

Case of the Season: Gossypiboma

70-year-old male with known rectal cancer presented with mild right lower quadrant discomfort, 3 years after surgical resection. He was otherwise well with no systemic complaints. An ultrasound of the abdomen and pelvis (Fig. 1A) was performed which revealed a mass in the right lower quadrant. The mass was seen as a curvilinear hyperechoic stripe with intense posterior acoustic shadowing. The remainder of the scan was unremarkable. For further characterization, the patient underwent a contrast-enhanced CT of the abdomen and pelvis. CT confirmed the presence of the heterogenous right lower quadrant mass (Fig. 1B) with a mildly hyperdense wall and a relatively hypodense center. This mass showed an eccentric area of marked hyperdensity associated with beam-hardening artifact (Fig. 1C). There was evidence of prior surgery with anastomotic sutures in the recto-sigmoid area (Fig. 1D). Inspection of the scout film (Fig. 1E) confirmed the characteristic appearance of a radio-opaque marker consistent with a retained surgical sponge. No therapeutic intervention was performed. The patient has been doing well clinically with a 7-year follow-up since the initial surgery with no change in the radiological appearance.

Amoebic perforation of the bowel: Experiences with 26 cases

Over a period of 14 1/2 years, 26 instances of amoebic perforation of the bowel occurring in 25 patients were treated surgically. Nineteen perforations occurred in males and 7 in females, whose ages ranged from 3 to 74 years. The duration of symptoms varied from 12 h up to 5 months (average 15 days). All patients were toxic and a right lower quadrant mass was present in 14. The correct diagnosis was made or suspected in 14 (54 per cent). Amoebic perforation of the bowel should be suspected in patients presenting with an acute abdomen if a past history of fever, pain and diarrhoea is obtained, particularly if a large tender mass is present in the right iliac fossa. Resectional surgery was performed in 7 patients, with a mortality of 71 per cent, whereas procedures designed to divert the faecal stream were carried out in 19, with a mortality of 43 per cent. All 6 patients with concomitant liver abscesses died. If these patients are excluded, the mortality from resections was 60 per cent and from faecal diversion 27 per cent. Faecal diversion with wide drainage is the treatment of choice for amoebic perforation of the colon.

Pseudomyxoma Peritonei Presenting as Vague Abdominal Discomfort

Case presentation: A 53-year-old man had noted a very vague sensation of abdominal discomfort for 1 year, which gradually increased over 2 months. He described diffuse abdominal fullness, without a change in weight, appetite, satiety, or abdominal girth. Physical examination was unremarkable. Initial evaluation, including abdominal ultrasound and upper GI endoscopy, was unrevealing. Colonoscopy suggested extrinsic compression of the cecum. Carcinoembryonic antigen level was markedly elevated at 74.8 (reference range 0–3.0 ng/ml). CT scan showed a number of large, soft-tissue masses infiltrating the abdomen and pelvis, and a relatively fixed right lower quadrant mass. A laparotomy was recommended. Operative findings: There were a number of large, mucinous-appearing implants present within the abdominal cavity, consistent with pseudomyxoma peritonei. The serosal surfaces of the spleen, gallbladder, and small bowel, and the diaphragm undersurface all contained several large implants. There were numerous pelvic implants as well. In the right lower quadrant, there was a 29 × 11 × 9 cm mass, which involved the appendix, ileum and right colon. Extensive cytoreductive surgery was performed, removing all bulky visible tumor. Pathology from all areas revealed Grade 2/4 mucinous adenocarcinoma, arising initially from the appendix. Post-operative therapy: Adjuvant therapy with 5-Fluorouracil was administered via two indwelling intraperitoneal catheters, followed by intraperitoneal infusion of chromic P-32 (radioactive phosphate). Discussion: Pseudomyxoma peritonei is an uncommon, often morbid condition in which mucinous adenocarcinoma deposits accumulate in the peritoneal cavity. The etiology is often a primary appendiceal tumor; however, in females ovarian primaries may be implicated. Pseudomyxoma peritonei may be found incidentally at laparotomy, or patients may present with abdominal pain, increased abdominal girth, and palpable abdominal masses. Treatment entails extensive surgical resection, followed by intraperitoneal chemotherapy. Prognosis with extensive disease can be poor, but complete cytoreductive surgery and chemotherapy improves survival. This case highlights the fact that some patients with pseudomyxoma peritonei present with very minimal symptoms, yet demonstrate extensive areas of intraabdominal tumor.