What could be causing this woman's abdominal pain and constipation?

CASE

A 66-year-old white female presented with complaints of abdominal pain and a 2-week history of a change in bowel habits. The pain was throbbing in nature and did not radiate. It was located bilaterally in the lower abdomen and was partially relieved by OTC analgesics. The patient reported the pain was originally a 9 in severity but was currently a 5. The onset of severe constipation coincided with the onset of abdominal pain. After using an enema, she experienced frequent episodes of diarrhea and one episode of bright red blood from the rectum on toilet paper. She reported having had two normal bowel movements that morning. Fevers were recorded by the patient ranging from 101°F to 102°F orally for the past 2 days, as well as a 5-lb weight loss over the past 2 weeks.

History The patient had a history of irritable bowel syndrome and diverticulosis. She reported that her grandchildren, for whom she is a caretaker, had gastroenteritis when her symptoms began. Her last colonoscopy, performed 2½ years ago, revealed left-sided diverticulosis and internal hemorrhoids. The patient's mother died from colon cancer at age 76 years. Her surgical history included an appendectomy and hysterectomy. She denied recent travel and did not take any prescription medications.

Physical examination The patient was afebrile and normotensive. Her abdomen was nondistended with active bowel sounds and without bruits. The ab domen was tympanic, and hepato splenomegaly was not appreciated. Pain was noted on light and deep palpation of the right and left lower quadrants. Tenderness was significantly greater in the left lower quadrant than in the right. There was guarding but no rigidity, referred pain, or rebound tenderness. She refused the rectal examination.

Diagnostic test results Laboratory tests results were WBC count, 20,500/ μL; neutrophils, 78%; lymphocytes, 15%; hemoglobin, 12 g/dL; hematocrit, 36.1%; platelets, 604 103/μL; ESR, 89 mm/h; C-reactive protein, 26.5 mg/L. Stool studies were ordered. CT of the abdomen (Figure 1) and pelvis was obtained with oral contrast because a BUN and creatinine level were not available.

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DISCUSSION

The patient had acute sigmoid diverticulitis with associated pericolonic phlegmon/early abscess formation and evidence of microperforation. The remainder of the GI tract was unremarkable.

Treatment The patient was instructed to go to the emergency department for further evaluation and treatment. She was started on IV ciprofl oxacin and metronidazole and was to have nothing by mouth for 2 days. As she improved clinically, her diet was advanced to clear liquids. On day 4 of her hospitalization, a follow-up CT of the abdomen and pelvis showed sigmoid diverticulitis with associated phlegmonous collection. A well-defined abscess was not seen at that time. She was placed on a low-residue diet.

After 7 days of hospitalization, she was discharged on oral ciprofloxacin, 500 mg twice a day, and metronidazole, 500 mg three times a day. Discharge instructions included follow-up with her gastroenterologist and a surgical evaluation for colon resection. The patient returned to our office and reported that the antibiotic course would be completed the following day. She was pain free but having frequent nonbloody loose bowel movements despite adhering to a low-residue diet. Based on her last CT scan, an additional week of oral antibiotics was prescribed. Follow-up CT of the abdomen and pelvis was ordered, as well as stool studies for Clostridium difficile. She was instructed to follow up with the surgeon.

Comment Diverticulitis represents a spectrum of inflammatory changes involving colonic diverticuli that range from subclinical inflammation to peritonitis to free perforation.¹ Patients with uncomplicated diverticulitis typically present with leukocytosis, a change in bowel habits, and pain in the left lower quadrant as the disease most commonly involves the sigmoid colon. More severe cases may manifest with the development of a phlegmon, abscess formation, fistulization, or generalized peritonitis. Diagnosis is confirmed by CT of the abdomen and pelvis.

Patients have been told to avoid eating nuts, corn, popcorn, and seeds to reduce the risk of complications associated with diverticulosis. However, results of a cohort study suggest that nuts, corn, and popcorn consumption was not associated with an increased risk of diverticulitis or diverticular bleeding and may be protective against developing diverticulosis.² JAAPA

Corri Wolf is on the faculty of the Department of Physician Assistant Studies, New York Institute of Technology, Old Westbury, New York. The author has indicated no relationships to disclose relating to the content of this article.

REFERENCES

1. Ludeman L, Warren BF, Shepherd NA. The pathology of diverticular disease. Best Pract Res Clin Gastroenterol. 2002;16(4):543-562.

2. Strate LL, Liu YL, Syngal S, et al. Nut, corn, and popcorn consumption and the incidence of diverticular disease. JAMA. 2008;300(8):907-914.