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Difficulty: EasyGastrointestinal and Abdominal Surgery

A 62-year-old man presents to the emergency department with a 2-day history of constant, worsening left lower quadrant abdominal pain. He also reports fever, mild nausea, and no bowel movements for the past 48 hours. His medical history is significant for hypertension and chronic constipation. His temperature is 38.6°C (101.5°F), blood pressure is 135/85 mm Hg, pulse is 92/min, and respirations are 16/min. Physical examination reveals focal tenderness to palpation in the left lower quadrant with voluntary guarding, but no rebound tenderness or diffuse rigidity. Laboratory studies show a leukocyte count of 14,000/mm³. Which of the following is the most appropriate next step in evaluation?

  1. Computed tomography scan of the abdomen and pelvisAnswer
  2. B
    Colonoscopy
  3. C
    Exploratory laparotomy
  4. D
    Barium enema
  5. E
    Abdominal ultrasonography

Answer

Computed tomography scan of the abdomen and pelvis
The patient's presentation of fever, left lower quadrant pain, and leukocytosis is highly suspicious for acute diverticulitis. In a hemodynamically stable patient without signs of generalized peritonitis, the most appropriate next step in evaluation is a computed tomography (CT) scan of the abdomen and pelvis. A CT scan can confirm the diagnosis by revealing colonic wall thickening and pericolic fat stranding, and it can also identify complications such as abscesses that might require percutaneous drainage or surgery.

Step-by-Step Solution

1
Identify the classic clinical presentation.
The patient has left lower quadrant pain, fever, and leukocytosis.
This triad is the classic presentation of acute diverticulitis, which is highly likely given his age and history of chronic constipation.
2
Assess for signs of complicated disease or acute abdomen.
The patient is hemodynamically stable and has focal (not diffuse) tenderness without rebound or rigidity.
The absence of generalized peritonitis or shock indicates that immediate surgical exploration is not required, and diagnostic imaging can be safely pursued.
3
Select the optimal diagnostic test.
A CT scan of the abdomen and pelvis is selected.
CT scan is the gold standard for confirming acute diverticulitis and evaluating for complications such as abscess, fistula, or contained perforation, while avoiding tests that increase perforation risk.

Key Concept

The diagnostic modality of choice for suspected acute diverticulitis in a hemodynamically stable patient without generalized peritonitis is a CT scan of the abdomen and pelvis with contrast.
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Topics

Gastrointestinal and Abdominal Surgery

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