A 60-Year-Old Man With Intense Left-Sided Abdominal Pain

Pramod Gupta, MD; Jitendra Gohil, MD

Disclosures

October 12, 2016

The differential diagnosis of acute sigmoid diverticulitis is broad and includes inflammatory bowel disease; irritable bowel syndrome; appendicitis; ischemic colitis; colon cancer; urolithiasis; urinary tract infection; and in women, numerous obstetric/gynecologic conditions, such as tubo-ovarian abscesses and ovarian cysts.

The complications of acute diverticulitis include formation of a pericolic abscess, frank colonic perforation leading to free intra-abdominal air, local adhesions, purulent or fecal peritonitis, sepsis, bowel obstruction, and fistula formation between the colon and the bladder or vagina. Fistula formation is more common in the setting of recurrent diverticulitis, with the most common type being a colovesicular fistula that is characterized by fecaluria, pneumaturia, or typical urinary tract infection symptoms.[1,2]

The initial evaluation of a patient with suspected acute diverticulitis generally includes physical examination; complete blood cell count; urinalysis; and, when indicated by the presence of peritonitis, plain radiography of the abdomen to rule out colonic perforation. Plain films are of limited value; however, they may show colonic obstruction, mild ileus, or bowel distention. Leukocytosis is found in only 36% of cases of acute diverticulitis.

The preferred imaging modality for diagnosis of acute diverticulitis is CT, because it both determines the extent of the disease and detects complications. Abdominal ultrasonography can also be used, but it lacks specificity and is operator-dependent. Barium contrast studies and colonoscopy/sigmoidoscopy should be avoided in the setting of acute diverticulitis because of the risk for bowel perforation; however, these examinations are often performed after resolution of the acute stage to evaluate for the presence of complications, such as fistula formation or other colonic abnormalities.[1,2]

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