A 56-year-old woman comes to the office due to abdominal pain and nausea. The patient has had 2 days of dull, persistent pain in the left lower abdomen that has progressively worsened. She has had no appetite and vomited once today. In addition, the patient has had mild urinary urgency with no dysuria or hematuria. She has not had a bowel movement during this period but is passing flatus. Medical history includes hypertension, type 2 diabetes mellitus, and an ovarian cyst. Temperature is 38 C (100.4 F), blood pressure is 134/82 mm Hg, and pulse is 94/min. BMI is 33 kg/m². Physical examination shows left lower quadrant abdominal tenderness with no rebound tenderness or guarding. No palpable abdominal mass or organomegaly is present. Bowel sounds are normoactive in all quadrants. The remainder of the examination shows no abnormalities. Urine dipstick is positive for leukocyte esterase and negative for nitrite. Which of the following is the most likely diagnosis?

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Explanation: 11ec25c8_d879_2e60_bc81_01cee1f7210b_MD0003_00 This patient's left lower abdominal pain, vomiting, anorexia, low-grade fever, and urinalysis findings likely indicate acute diverticulitis, a complication of diverticulosis. Diverticulosis is characterized by herniation of the colonic mucosa/submucosa through the circular and longitudinal muscle layer due to elevated intraluminal pressure. Risk increases with age and is greatest in those with obesity, poor diet (eg, low dietary fiber, high red meat), and tobacco use. Although diverticulosis is usually asymptomatic, approximately 5%-15% of patients develop diverticular bleeding or diverticulitis. In diverticulitis, elevated luminal pressure or inspissated food particles cause erosion of the diverticular wall, leading to micro- or macroperforation and subsequent colonic wall inflammation. Most cases arise in the sigmoid colon (the site of the greatest intraluminal pressure) and present with the following: Left lower quadrant abdominal pain Nausea and vomiting Bladder symptoms (eg, urgency, frequency, dysuria) or sterile pyuria (eg, positive leukocyte esterase, negative nitrite/bacteria) due to bladder irritation from adjacent sigmoid colon inflammation Alteration in bowel habits (eg, constipation, diarrhea) A minority of patients (<20%) develop rebound tenderness/guarding or a tender left lower quadrant mass. Diagnosis is usually made with imaging (eg, CT scan of the abdomen); antibiotic therapy is generally curative, but complications (eg, abscess, bowel obstruction, frank perforation, fistula) can occur and usually necessitate further therapy. (Choice A) Acute bacterial cystitis is common in women and is usually marked by dysuria, suprapubic pain, and positive leukocyte esterase on urinalysis (indicating pyuria). However, patients with cystitis typically have no systemic symptoms (eg, fever, vomiting), left lower quadrant pain, or anorexia. In addition, urinary nitrites are often (but not always) present. (Choice C) Ovarian torsion usually causes pelvic pain, nausea/vomiting, and (occasionally) fever. However, the pain is often acute and severe, and most patients have a palpable adnexal mass. (Choice D) Ruptured ovarian cysts most often present with severe, sudden-onset abdominal pain following sexual intercourse. The vast majority of cases occur in females of reproductive age. (Choice E) Small bowel obstruction usually occurs in individuals who have had a previous abdominal or pelvic surgery and developed postoperative adhesions or hernia. Although nausea/vomiting and low-grade fever can occur, patients typically have paroxysms of periumbilical crampy abdominal pain (not dull, persistent, left lower quadrant pain) and often cannot pass flatus. In addition, high-pitched bowel sounds are often present. Educational objective: Acute diverticulitis is common in older individuals and typically presents with dull, left lower quadrant pain; nausea and vomiting; alteration in bowel habits; and (sometimes) irritative bladder symptoms (eg, dysuria, frequency) or sterile pyuria. References: Obesity increases the risks of diverticulitis and diverticular bleeding. (http://www.ncbi.nlm.nih.gov/pubmed/18996378) Meat intake and risk of diverticulitis among men. (http://www.ncbi.nlm.nih.gov/pubmed/28069830) Western dietary pattern increases, and prudent dietary pattern decreases, risk of incident diverticulitis in a prospective cohort study. (http://www.ncbi.nlm.nih.gov/pubmed/28065788)

A 56-Year-Old Woman Comes to the Office Due to Abdominal