Lower Left Quadrant Pain in a 67-Year-Old Male (Case 4)

Chapter 14 Lower Left Quadrant Pain in a 67-Year-Old Male (Case 4)



Rebecca S. Evangelista, MD




Differential Diagnosis













Diverticulitis Ischemic colitis Colon cancer
Hernia Ureterolithiasis Gastroenteritis



Speaking Intelligently


When I’m asked to see a 67-year-old male who presents with complaints of LLQ pain, first I try to separate infectious from noninfectious causes. I ask about onset of symptoms, bowel habits, previous hx of similar episodes, GI symptoms, and hx of previous colonoscopy. I ask specific questions to determine if the patient is clinically obstructed. During the physical examination I look for focal versus diffuse abdominal tenderness and any signs of masses or hernias. I obtain a U/A, Chem 7, and CBC for starters; if tachycardia and hypotension are present, particularly in the face of peritoneal signs, I bolus IV fluids and seriously entertain the dx of perforated diverticulitis. Noncomplicated diverticulitis is often the clinical dx in this scenario, but if unclear, an upright abdominal x-ray and CT of the abdomen and pelvis can be helpful. When the CT shows thickening of the bowel wall without evidence of diverticuli, dx of an enteritis versus ischemic colitis may be made by endoscopic evaluation of the mucosa.



PATIENT CARE



Clinical Thinking



• Keep in mind which surgical conditions in the differential dx would lead to trouble quickly. In this differential dx, perforation secondary to diverticulitis, carcinoma, or ischemia would require urgent surgical intervention.

• As you proceed with the physical examination, keep in mind which entities are likely to present with peritoneal findings (tenderness, guarding, and rebound).


History



• Consider the nature, duration, and type of pain. Where did it begin and where is it now?

• Noncomplicated diverticulitis typically begins with vague LLQ discomfort and continues to worsen with time. Complicated diverticulitis (perforation, abscess, or obstruction) can present with a more acute onset of LLQ pain that may or may not have started as noncomplicated diverticulitis.

• Gastroenteritis is commonly associated with diarrhea in the absence of peritoneal findings. Ischemic colitis may present similarly to gastroenteritis except for the addition of bloody diarrhea, and is more common in patients with a hx of cardiovascular or peripheral vascular disease.

• Colon cancer is usually not an acute presentation, but can present with acute symptoms if it is associated with perforation or obstruction.

• Hernias causing LLQ pain may be inguinal, incisional, or, very rarely, Spigelian, and should present with an associated mass.

• Ureterolithiasis is usually associated with “colicky pain” that waxes and wanes, and the presence of hematuria.


Physical Examination



• VS: Fever suggests an inflammatory process. Hypotension and/or tachycardia can be associated with dehydration, hypovolemia, or sepsis secondary to perforated viscus or abscess.

• Observation: patients with colicky pain can’t find a position of comfort, whereas patients with peritoneal findings prefer to lie still.

• Peritoneal findings (tenderness, guarding, rebound) are more likely in diverticulitis, perforated colon cancer, and hernias with incarceration and/or strangulation. Not present in gastroenteritis, uncomplicated ischemic colitis, and ureterolithiasis.

• Decreased bowel sounds are more frequently associated with a GI inflammatory process than a GU process. More diffuse lower abdominal tenderness suggests perforation.

• Palpate for masses in the LLQ and in locations of potential hernias (left groin and previous incisions). A mass in the abdominal wall suggests an incarcerated hernia. An intra-abdominal mass suggests complicated diverticulitis or carcinoma.

• Rectal examination: evaluate for tenderness, mass or blood.


Tests for Consideration


















• CBC: leukocytosis suggests an inflammatory process.
 $35

• Chem 7: look for acidosis and dehydration with elevated creatinine.
 $29

• U/A: for hematuria.
 $38

• Sigmoidoscopy: may help r/o ischemic colitis and distal colon cancer.
 $175



IMAGING CONSIDERATIONS











→ Obstruction series: Erect CXR and two-view abdomen series to evaluate for pneumoperitoneum, bowel obstruction, or pulmonary process.
 $175

→ CT of abdomen/pelvis with oral/IV contrast: Imaging modality of choice in the evaluation of diverticulitis. Oral and IV contrast are absolute necessities to evaluate the GI tract. In addition to increased sensitivity to perforation and free intraperitoneal air, complications of bowel perforation such as fistulae and abscess are readily shown. Other forms of colitis may show characteristic findings and the GU tract is well evaluated.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Lower Left Quadrant Pain in a 67-Year-Old Male (Case 4)

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