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

Pramod Gupta, MD; Jitendra Gohil, MD

Disclosures

October 12, 2016

Discussion

Acute diverticulitis results from inflammation of a diverticulum (small mucosal and submucosal herniations through the circular muscle layer of the colonic wall) secondary to fecal obstruction. The obstruction typically occurs at the neck of the diverticulum; solidified stool, which typically forms a fecalith, abrades the mucosa within or at the neck of the diverticulum.

In uncomplicated cases (typically characterized by a well-appearing patient without peritonitis and systemic signs/symptoms), the inflammatory process is confined to the colonic wall; however, the obstruction, with subsequent high intraluminal pressure within the diverticula, can lead to a microperforation that in turn allows translocation of bacteria through the colonic wall, formation of a pericolic abscess, and diffuse peritonitis.

Only 2%-4% of patients diagnosed with diverticulitis are younger than 40 years; the condition is predominantly found in elderly populations.[1,2]

Diverticulosis is an intestinal disorder that is characterized by the presence of many diverticula; it occurs equally in men and women, with a higher prevalence in cultures with a low-fiber diet (which is believed to decrease stool transit time, thereby causing increased intraluminal pressure and resulting in mucosal herniations). The colonic diverticula themselves are most commonly found in the sigmoid and descending colon, although less commonly, patients (particularly those of Asian descent) develop diverticula of the right colon. Approximately one third of the population has diverticulosis by age 50 years, and about two thirds have it by age 85 years. Approximately 10%-25% of patients with known diverticulosis go on to develop diverticulitis.[1,2]

The classic presentation of diverticulitis is steady, deep abdominal pain that is often initially diffuse and vague, but later localizes in the left lower quadrant of the abdomen. Abdominal bloating; stool changes, such as diarrhea or constipation; and flatulence frequently accompany acute diverticulitis. Fever, fatigue, and anorexia are also common symptoms. Colonic inflammation may irritate the bladder or the ureters, leading to urinary frequency and dysuria.

Physical examination may reveal fever; localized, left lower quadrant abdominal tenderness; mild abdominal distention; and, at times, a left lower quadrant mass. The palpated mass is likely to be inflamed loops of bowel or, possibly, an abscess. Digital rectal examination may demonstrate left-sided tenderness and occult blood in the stool.[1,2]

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