Learning Objectives
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Learn the common causes of abdominal pain.
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Develop an understanding of the unique anatomy of the colon.
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Develop an understanding of the causes of diverticulitis.
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Develop an understanding of the differential diagnosis of diverticulitis.
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Learn the clinical presentation of diverticulitis.
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Learn how to examine the abdomen.
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Learn how to use physical examination to identify diverticulitis.
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Develop an understanding of the treatment options for diverticulitis.
Mai Huang
Mai Huang is a 64-year-old waitress with the chief complaint of, “My belly hurts.” Mai stated that over the past week or so, she felt constipated, and for the last few days, she’s been experiencing crampy pain in her left lower abdomen. Mai stated that she woke up today feeling like she had the stomach flu and felt like she had a fever. She called her daughter, who said that Mai probably had appendicitis and that she needed to go to the emergency room. Instead she called our office, and we worked her in. “Doctor, I am so sorry to bother you. I am sure this is nothing. I just wanted to be able to tell my daughter Sally that it was just the flu. You know how daughters can be.” I reassured her that I understood and would do everything I could to get things sorted out, and if she wanted I’d be happy to give Sally a call. “So, Mai, have you ever had anything like this before?” She said, “No Doctor, never.” I asked, “Have you had any previous abdominal pain?” She replied, “No, never.”
I asked Mai what made the pain worse, and she said that when she came over to the office on the bus, every time the bus hit a bump, it would jar her belly and make it hurt. “Also, Doctor, and this is embarrassing, I am having a lot of gas.” I asked, “Anything else?” She said that she felt like she was bloated, but really any activity made the pain worse. I asked her what made the pain better, and she said that she tried to drink some hot tea because she didn’t have much of an appetite, but the pain just wasn’t getting any better. In fact, it seemed to be a little worse. Mai denied significant sleep disturbance.
I asked Mai to point with one finger to show me where it hurt the most, and she immediately pointed to her left lower quadrant.
On physical examination, Mai was febrile, with a temperature of 100.6°F. Her respirations were 18, and her pulse was 78 and regular. Her blood pressure was 106/72. Mai’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was her cardiopulmonary examination. Her thyroid was normal. Her abdominal examination revealed tenderness in the left lower quadrant, and I thought that I could feel a mass. Bowel sounds were diminished, with no organomegaly. Mai had mild costovertebral angle (CVA) tenderness on the left. There was no peripheral edema. Her low back examination was normal. Visual inspection of the abdomen was unremarkable. A careful neurologic examination was normal.
Key Clinical Points—What’s Important and What’s Not
The History
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Several-day history of change in bowel habits, with constipation and later increased flatulence
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Fever
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Left-sided abdominal pain that is worsening
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Feeling systemically ill
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Pain made worse by activity or doing things that jar the abdomen
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No other past history of abdominal pain
The Physical Examination
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Patient is febrile
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Obvious tenderness in the left lower quadrant
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Palpation of a mass in the left lower quadrant
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Hypoactive bowel sounds
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Left CVA tenderness
Oher Findings of Note
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Normal HEENT examination
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Normal cardiovascular examination
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Normal pulmonary examination
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No peripheral edema
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Normal neurologic examination
What Tests Would You Like to Order?
The following tests were ordered:
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Computed tomography (CT) of the abdomen
Test Results
CT scanning with contrast enhancement revealed perforated diverticulitis of the sigmoid as evidenced by extraluminal gas and fluid surrounding the sigmoid colon, as well as the finding of extraluminal fecal bowel contents near the site of perforation ( Fig. 15.1 ).
Clinical Correlation—Putting It All Together
What is the diagnosis?
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Diverticulitis with perforation
The Science Behind the Diagnosis
Clinical Syndrome
Diverticulitis is a common cause of acute abdominal pain in Western and industrialized countries. Found more commonly in women, the disease occurs more commonly after the fourth decade. Diverticulitis occurs when small herniations of the colonic mucosa and submucosa, known as diverticula, become inflamed or tear ( Fig. 15.2 ). It is estimated that approximately 75% of patients will have diverticula by the age of 80, as there is age-related weakening of the abdominal wall in areas of insertion of the vasa recta. Decreased bowel motility of senescence may also play a role in increasing intracolonic pressure, as may changes in the microbiome of the gastrointestinal tract.
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