A 72-year-old woman with a history of narcotic bowel syndrome and multiple prior abdominal surgeries presents to the emergency department (ED) for severe right lower abdominal and rectal pain that has been present over the past week. She visited another ED 2 days prior for the same pain, but it has worsened. She denies fevers, chills, nausea, vomiting, diarrhea, bleeding or melena, hematuria, dysuria, or other complaints.

Vital Signs and Physical Examination

The patient’s vital signs are remarkable for elevated pulse rate (103 beats per minute), blood pressure (190/110 mm Hg), and respiratory rate (24 breaths per minute). Physical examination is notable for moderate distress and diffuse lower abdominal tenderness without rebound. Rectal examination shows a large stool ball. Initial diagnostic tests include blood work and computed tomography scan of the patient’s abdomen (Figure). The patient’s laboratory values and liver function tests are within normal range except for a white blood cell count of 12,000/µL with 77% polymorphonuclear leukocytes.

Can you diagnose this condition? What is the best next step in testing and treatment?

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