A 49-year-old male presenting for vague abdominal discomfort, lack of appetite, and no bowel movements has a large differential diagnosis. The causes of the symptoms may be diverse and tangential fields such as nutrition and psychiatry must be considered aside from bowel pathology. The bowel pathologies that must be considered are obstructions, infections, ischemia, and perforations of the underlying anatomy. Given the history of appendix surgery, adhesions must be considered as well. Peritonitis is unlikely due to the lack of rebound and the vague localization of the pain. The most likely diagnosis is a diverticulitis. Diverticulitis is the most likely culprit because of the abdominal distention, diminished bowel sounds, and the tenderness without rebound (Harrison’s, 2008, p. 1904). Furthermore, the slightly elevated temperature, accelerated respirations and moderate systolic hypertension are consistent with the presentation of an uncomplicated diverticulum (Harrison’s, 2008, p. 1904).
The history and the physical examination provide the necessary clues to reach the conclusion of diverticula. The localization of the pain in the lower left quadrant (LLQ) without rebound of the abdominal muscles on palpitation provides perhaps the most important clue. LLQ pain is usually a result of inflammatory bowel disease or diverticulitis (First Aid, 2010, p. 105). The lack of bloody diarrhea in the history indicates that the underlying pathology is ulcerative colitis. Furthermore, the sudden onset of symptomology is suggestive that it is not Chron’s disease (First Aid, 2010, p. 134). Ischemic disease of the bowel is similarly unlikely because of the general nature of the discomfort and the only moderately elevated vital signs in the patient.
The etiology of this patient’s symptoms may by a diverticulosis, which is simply a condition where a sac like protrusion herniates through a defect in the muscular layer of the colon. They commonly occur in the sigmoid colon and can cause severe bleeding if they interact with a blood vessel. They are most commonly caused by a lack of fiber in the diet as is often seen in the patient’s demographic group (First Aid, 2010, p. 132). A likely complication of diverticulosis is diverticulitis, which is an infection subsequent to the diverticulosis. In order to properly conclude that the patient is suffering from a diverticulitis, a CT scan is required to show areas of inflammation (First Aid, 2010, p. 132). Management of diverticular disease is dependent on the severity of the presentation. An accidentally discovered diverticulosis is best approached with a change of diet, particularly a significant increase in the amount of fiber (Harrison’s, 2008, p. 1904). In patients with symptomatic disease, such as our patient, antibiotics are indicated particularly trimethoprim/sulfamethoxazole, or ciprofloxacin (Harrison’s, 2008, p. 1905). There is debate in the literature regarding whether or not restricting intake of food impacts the disease course at all (Harrison’s, 2008, p. 1904) (First Aid, 2010, p. 132). If the diverticular abscess is large than it’s recommended that the abscess be drained. If there is a free perforation surgery is necessary to remove the necrotic tissue, and repair the colon (Fagenholz, de Moya, 2013). Hopefully this patient is responsive to simple antibiotic therapy. However, the likelihood for relapse is high (Tursi, 2013), and it is important that proactive steps be taken to prevent recurrence. A high-fiber diet, non-absorbable antibiotics such as rifaximin, 5-aminosalicylic acid, and probiotics all play a role in prophylaxis of future diverticulitis and causing a remission of the underlying diverticulosis.
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