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Abdominal x-ray
0%
0/5
Lipase
Abdominal CT
100%
5/5
Left lower quadrant ultrasound
Emergent colonoscopy
Select Answer to see Preferred Response
This patient most likely has acute diverticulitis, which is inflammation of colonic diverticula. CT scan is the modality of choice for the diagnosis of diverticulitis, with findings including pericolic fat stranding and bowel wall thickening. Diverticulitis is the most common complication of diverticular disease. Diverticula are outpouchings of the colonic mucosa through weak points in the bowel wall. They are present in 35-50% of the general population, with increased prevalence in the elderly and those with chronic constipation. Diverticulitis occurs when a diverticulum becomes obstructed, leading to inflammation, ischemia, and infection. This may progress to abscess formation or perforation with generalized peritonitis. Diverticulitis typically presents with left lower quadrant abdominal pain, fever, elevated white blood cell count with a left shift, and guaiac-positive stool. Though diverticula occur more often on the left side of the colon, those that rupture tend to occur on the right side. Wilkins et al. review the diagnosis and management of acute diverticulitis. They suggest that hospitalization should be considered if patients have signs of peritonitis or if there is suspicion for complicated diverticulitis. Of note, they write that 15 to 30% of patients admitted with acute diverticulitis will require surgical intervention. Longstreth et al. investigate the diagnoses of inflammatory bowel syndrome (IBS) and diverticulitis. They report evidence of misattribution of IBS pain to diverticulitis, especially in outpatients who were not worked up with a CT scan. This results in unnecessary antibiotic use. Illustration A shows a CT scan of a patient with acute diverticulitis. Note the bowel wall thickening and pericolic fat stranding inside the white circle. Incorrect Answers: Answer 1: Abdominal x-ray may reveal an ileus in the setting of diverticulitis, but it is not sensitive for the diagnosis of diverticulitis. Answer 2: Lipase levels are sensitive for the diagnosis of pancreatitis, not diverticulitis. Answer 4: Left lower quadrant ultrasound is not as sensitive as CT scan for the diagnosis of diverticulitis. Answer 5: Colonoscopy should be avoided in suspected cases of acute diverticulitis due to the risk of perforation.
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