Surgery

69 year old man with abdominal pain

Katherine Bakke on Jan 16, 2017

A 69-year old man presents to the ER with lower abdominal pain that began 3 hours ago. He has never had this symptom before. The pain is sharp in quality and has been constant since its onset. He notices no difference in the pain upon movement, and the pain does not radiate to the back or scrotum. He feels warm but denies shaking chills, and he feels nauseated but has not vomited. He denies bright red blood per rectum. His last bowel movement was yesterday afternoon and described as normal in appearance. He denies urinary frequency, urgency, and dysuria.

HIs past medical history includes hypertension, hyperlipidemia, an unrepaired left inguinal hernia, and osteoarthritis of both knees. He has never had surgery. A brother was diagnosed with colon cancer at age 63. He has a diet poor in fiber, and after retiring from his job as a construction foreman five years ago, leads a largely sedentary lifestyle. He is a former 1-pack-per-day smoker, quitting at the age of 60. He has never had a screening colonoscopy.

Medications include:  HCTZ 12.5 mg BID, simvastatin 20 mg daily, ASA 81 mg daily, ibuprofen 600 mg PRN.

Vitals:  Temp 99 F  HR 95  BP 145/80  RR 12  O2 98% on Room Air

On physical exam, the patient is in mild distress. Cardiac exam reveals a regular rate and rhythm without murmurs, rubs, or gallops. Lungs are clear to auscultation and percussion bilaterally. Abdomen is mildly distended and there is pain in the left lower quadrant on palpation. No rebound or guarding is present. There is a reducible left inguinal hernia. Bowel sounds are decreased. Rectal exam reveals mildly enlarged prostate without tenderness.

Based on history and physical, what is your differential diagnosis?

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Click here for a suggested differential.
When a patient presents with acute abdominal pain, you first want to identify the location of the pain, and build your differential based on possible pathology of the organs/structures in that location. In this gentleman, the pain is in the lower abdomen, specifically the left lower quadrant. Diagnoses to consider include: Diverticulitis, appendicitis, inflammatory bowel disease, gastroenteritis, bowel obstruction, colorectal cancer, ischemic colitis, incarcerated or strangulated hernia, cystitis, pyelonephritis, nephrolithiasis, AAA, or other retroperitoneal process.


What lab and imaging tests would you like to perform?

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Click here for answer.
CBC, electrolytes, amylase/lipase, LFTs, urinalysis, abdominal x-ray (upright and supine), abdominal CT, fecal occult blood test.


Would you consider performing a colonoscopy on this patient?

Expand all answers
Yes.
No, not yet. While it is true that he has never had a colonoscopy, our differential includes diverticulitis and other active inflammatory processes. Until we rule out these pathologies, we should refrain from colonoscopy because of the risk of visceral perforation [1].


No.
Correct. While it is true that he has never had a colonoscopy, our differential includes diverticulitis and other active inflammatory processes. Until we rule out these pathologies, we should refrain from colonoscopy because of the risk of visceral perforation [1].


  1. 3. Feingold D, Steele SR, Lee S, et al; Clinical Practice Guideline Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94

A 69-year old man presents to the ER with lower abdominal pain that began 3 hours ago. He has never had this symptom before. The pain is sharp in quality and has been constant since its onset. He notices no difference in the pain upon movement, and the pain does not radiate to the back or scrotum. He feels warm but denies shaking chills, and he feels nauseated but has not vomited. He denies bright red blood per rectum. His last bowel movement was yesterday afternoon and described as normal in appearance. He denies urinary frequency, urgency, and dysuria.

HIs past medical history includes hypertension, hyperlipidemia, an unrepaired left inguinal hernia, and osteoarthritis of both knees. He has never had surgery. A brother was diagnosed with colon cancer at age 63. He has a diet poor in fiber, and after retiring from his job as a construction foreman five years ago, leads a largely sedentary lifestyle. He is a former 1-pack-per-day smoker, quitting at the age of 60. He has never had a screening colonoscopy.

Medications include:  HCTZ 12.5 mg BID, simvastatin 20 mg daily, ASA 81 mg daily, ibuprofen 600 mg PRN.

Vitals:  Temp 99 F  HR 95  BP 145/80  RR 12  O2 98% on Room Air

On physical exam, the patient is in mild distress. Cardiac exam reveals a regular rate and rhythm without murmurs, rubs, or gallops. Lungs are clear to auscultation and percussion bilaterally. Abdomen is mildly distended and there is pain in the left lower quadrant on palpation. No rebound or guarding is present. There is a reducible left inguinal hernia. Bowel sounds are decreased. Rectal exam reveals mildly enlarged prostate without tenderness.

Based on history and physical, what is your differential diagnosis?

Expand all answers
Click here for a suggested differential.
When a patient presents with acute abdominal pain, you first want to identify the location of the pain, and build your differential based on possible pathology of the organs/structures in that location. In this gentleman, the pain is in the lower abdomen, specifically the left lower quadrant. Diagnoses to consider include: Diverticulitis, appendicitis, inflammatory bowel disease, gastroenteritis, bowel obstruction, colorectal cancer, ischemic colitis, incarcerated or strangulated hernia, cystitis, pyelonephritis, nephrolithiasis, AAA, or other retroperitoneal process.


What lab and imaging tests would you like to perform?

Expand all answers
Click here for answer.
CBC, electrolytes, amylase/lipase, LFTs, urinalysis, abdominal x-ray (upright and supine), abdominal CT, fecal occult blood test.


Would you consider performing a colonoscopy on this patient?

Expand all answers
Yes.
No, not yet. While it is true that he has never had a colonoscopy, our differential includes diverticulitis and other active inflammatory processes. Until we rule out these pathologies, we should refrain from colonoscopy because of the risk of visceral perforation [1].


No.
Correct. While it is true that he has never had a colonoscopy, our differential includes diverticulitis and other active inflammatory processes. Until we rule out these pathologies, we should refrain from colonoscopy because of the risk of visceral perforation [1].


  1. 3. Feingold D, Steele SR, Lee S, et al; Clinical Practice Guideline Task Force of the American Society of Colon and Rectal Surgeons. Practice parameters for the treatment of sigmoid diverticulitis. Dis Colon Rectum. 2014 Mar;57(3):284-94

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