August 12, 2012

70 year old female with left lower quadrant abdominal pain

A 70 year old female patient presents with new onset of left lower quadrant abdominal pain, a low-grade fever, focal tenderness with guarding and an elevated white blood cell count.

The most likely diagnosis is:

a) endometrioma
b) hemorrhagic ovarian cyst
c) tubo-ovarian abscess
d) ovarian torsion
e) diverticulitis






ANSWER
The correct answer is E


Explanation
The diagnosis of acute diverticulitis should be suspected in an older patient who presents with new onset of left lower quadrant abdominal pain, low-grade fever, focal tenderness with or without guarding, and an elevated white blood cell count.

Nausea, vomiting, and diarrhea or constipation may accompany the bowel complaints and simulate gastroenteritis. Absence of bowel sounds suggests peritoneal inflammation.

In situations of diagnostic uncertainty, confirmatory testing can be obtained. Proctosigmoidoscopy performed with a flexible sigmoidoscope can be done comfortably, safely, and with a minimum of bowel preparation when it is essential to rule out other causes of serious colonic pathology, such as inflammatory bowel disease and cancer.

Inability to pass the flexible sigmoidoscope beyond the rectosigmoid junction due to acute bowel inflammation is strongly suggestive of acute diverticulitis. Barium enema will identify diverticulitis; contrast outside the bowel lumen is an important diagnostic feature.

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