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An 8 1 ⁄ 2 -year-old girl was admitted to the hospital because of an abdominal mass and pain.The child had had recurrent abdominal pain during the preceding two years. Her mother believed that the symptoms had begun at about the time that an elevated coliform count was discovered in the local water supply. Seventeen months before admission, the girl's blood count and sedimentation rate were normal, and stool examination showed no ova or parasites. Seven weeks before admission, intermittent fevers began, with anorexia, loss of about 4.5 kg in weight, and a reduction in the frequency of bowel movements. Six weeks before admission, a radiograph of the abdomen showed a nonspecific pattern of bowel gas and stool throughout the colon; there was a calcified nodule in the right upper quadrant that was consistent with the presence of a gallstone. Treatment with mineral oil was recommended, but it provoked vomiting and was discontinued. Five days before admission, the child began to vomit all ingested foods and liquids. She had fever and diarrhea, with dark stools but no obvious hematochezia. Two days later, her temperature rose to 39.9°C.Two days before her admission to this hospital, the girl was admitted to another hospital because of increasing abdominal pain and persistent vomiting; there was little oral intake and no vomiting at that time. Examination revealed dehydration and diffuse abdominal tenderness without signs of peritoneal irritation, organomegaly, or a mass. The urine was normal. Laboratory tests were performed (Tables 1 and 2). An abdominal radiograph showed a moderate amount of stool in the right side of the colon and in the rectosigmoid. There was little or no bowel gas in the left portion of the abdomen. No distended bowel loops or masses were detected, and the psoas shadows were normal.Fluids and electrolytes were given. On the evening of the first hospital day, the patient passed a bloody stool, and ceftriaxone and metronidazole were administered. On the next evening, she vomited dark liquid, and piperacillin-tazobactam and gentamicin were substituted. There was no further vomiting. On the third hospital day, the hematocrit was 27.9 percent. An abdominal radiograph (Fig. 1) showed a gallstone in the right upper quadrant and a large mass with an air-fluid level in the left upper quadrant. The distal portions of the small intestine were not dilated. A computed tomographic (CT) scan of the abdomen and pelvis (Fig. 2), obtained after the oral and intravenous administration of contrast material, showed a large mass containing contrast material and an airfluid level in the left upper quadrant. The mass had a T ABLE 1. H EMATOLOGIC L ABORATORY V ALUES .

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