Question 8#

A 60-year-old woman complains of fever and constant left lower quadrant pain of 2-day duration. She has not had vomiting or rectal bleeding. She has a history of hypertension but is otherwise healthy. She has never had similar abdominal pain, and has had no previous surgeries. Her only regular medication is lisinopril. On examination blood pressure is 150/80, pulse 110, and temperature 38.9°C (102°F). She has normal bowel sounds and left lower quadrant abdominal tenderness with rebound. A complete blood count reveals WBC = 28,000. Serum electrolytes, BUN, creatinine, and liver function tests are normal.

What is the next best step in evaluating this patient’s problem

a. Colonoscopy
b. Barium enema
c. Exploratory laparotomy
d. Ultrasound of the abdomen
e. CT scan of the abdomen and pelvis

Correct Answer is E


The most likely diagnosis in this patient is acute diverticulitis. Diverticulitis results from obstruction of a preexisting colon diverticulum. Colonic diverticulosis is very common in Western societies, and over half of Americans older than 60 have diverticula. Diverticulosis is asymptomatic. However, obstruction of a diverticulum can result in a microscopic perforation contained by the mesentery, or frank perforation and development of a peridiverticular abscess. Diverticulitis is classically associated with abdominal pain and fever. The pain is typically located in the left lower quadrant because the sigmoid is the most common region of the colon to be affected by diverticulosis. The marked leukocytosis in this patient combined with rebound tenderness suggests the possibility of a peridiverticular abscess. Diverticulitis can usually be diagnosed by CT scan of the abdomen and pelvis, which can also detect an associated diver-ticular abscess. Abdominal ultrasound is rarely useful in assessing colon pathology. Diverticulitis should be treated with antibiotics that are effective against coliforms and anaerobes. A typical choice is ciprofloxacin and metronidazole. Diverticular abscesses frequently require drainage, which can often be done percutaneously. Surgery is reserved for cases refractory to antibiotics and percutaneous drainage. Because of the increased risk of colon perforation, colonoscopy and barium enema are usually deferred for 4 to 6 weeks in patients with acute diverticulitis.