A 73-year-old woman is brought to the clinic by her niece due to a 10-day history of abdominal pain and loss of appetite. The patient does not like "going to the doctor" and has not been seen by a physician in many years. Frequent loose stools and loss of appetite have been present since the pain began. Family history is significant for colon cancer in a maternal aunt. Temperature is 37.8 C (100 F) and pulse is 98/min. Abdominal examination is significant for tenderness on deep palpation of the left lower quadrant, along with an appreciable mass. There is no inguinal lymphadenopathy. White blood cell count is 15,000/mm³. Which of the following is the most likely cause of the abdominal pain in this patient?

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11ec160b_3941_d6e2_9249_033920f3629b_MD0001_00 This patient with abdominal pain, leukocytosis, low-grade fever, and a mass palpated in the left lower quadrant likely has acute diverticulitis. Diverticulitis is characterized by inflammation of colonic diverticula (ie, herniated outpouchings of the colonic mucosa and submucosa through the muscularis mucosae) and is caused by trapped food particles and elevated intraluminal pressure within a diverticulum, resulting in microperforation. The risk increases with age (particularly in those age ≥60). Patients commonly present with constant abdominal pain, classically in the left lower quadrant, signifying sigmoid colon involvement. Other symptoms include nausea, vomiting, and changes in bowel habits (constipation or diarrhea). Patients often have low-grade fever, and examination may reveal lower abdominal tenderness and, often, a palpable mass due to inflammation or abscess formation. Mild leukocytosis is a common laboratory finding; occult blood may be present, but gross hematochezia is rare. (Choice B) Colon cancer may present with abdominal pain. However, a tumor large enough to palpate on examination suggests extensive disease and would typically be associated with more chronic symptoms (eg, weight loss). The leukocytosis and short duration of symptoms in this patient are more consistent with diverticulitis. (Choice C) Incarcerated direct inguinal hernias cause a palpable mass; however, the mass would typically be in the groin, not the abdomen. In addition, unless the hernia is strangulated, leukocytosis and fevers are unexpected. (Choice D) Ischemic colitis is a common cause of abdominal pain in an older patient; however, it typically presents with hematochezia and postprandial pain in patients with ischemic risk factors (eg, hypertension, diabetes). (Choice E) Tubo-ovarian abscess can cause abdominal pain and leukocytosis; however, patients typically have vaginal discharge, and a mass (if present) is located in the pelvis, not the abdomen. Tubo-ovarian abscesses typically occur in the setting of pelvic inflammatory disease, which is far more common in patients age <40. (Choice F) Ulcerative colitis often presents with abdominal pain and diarrhea; however, hematochezia is common. In addition, patients are typically diagnosed at age 20-40. Educational objective: Diverticulitis is characterized by inflammation of colonic diverticula. Patients have abdominal pain, nausea, vomiting, and changes in bowel habits. Low-grade fever and leukocytosis are common, and physical examination may demonstrate a tender mass in the left lower quadrant. __________ References: Diagnosis and management of acute diverticulitis. (http://www.ncbi.nlm.nih.gov/pubmed/23668524)

A 73-Year-Old Woman Is Brought to the Clinic by Her