Lower abdominal pain in a 77-year-old woman

Published on 10/04/2015 by admin

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Problem 16 Lower abdominal pain in a 77-year-old woman

Naseem Mirbagheri, Stewart Skinner

A 77-year-old woman presents to the emergency department with acute abdominal pain. She had been feeling unwell over the previous 2 days with left iliac fossa discomfort and constipation. This morning she woke from sleep with worsening acute lower abdominal pain, mainly on the left lower side of her abdomen, constant in nature and aggravated by movement. The pain was associated with some nausea and vomiting. There had been no bowel action for 3 days. There was no rectal bleeding.

Q.1

What is the most likely diagnosis and what other conditions must be considered?

There is nothing else from the history that helps towards a diagnosis. Her past history is unremarkable apart from hypertension for which she takes perindopril. The patient is unwell and dehydrated. Her heart rate is 120 bpm and regular, blood pressure 90/70 mmHg and temperature 38°C. Her abdomen is soft apart from an area of localized tenderness in the left iliac fossa. Rectal examination is normal with some soft faeces present.

Q.2

What is the clinical problem, what should your initial management plan be and what investigations should be arranged?

You decide to perform arterial blood gases to determine the pH and lactate levels as you are worried about the possibility the patient may have ischaemic bowel. The results are shown below (the normal range is in parentheses).

Investigation 16.1 Summary of results

pH 7.2 (7.38–7.43)
pCO2 36 mmHg (35–45)
HCO3 16 (20–24)
Lactate 1.42 (0.50–2.00)
Base excess −9.3 (−3.3–1.2)
K 3.5 (3.8–5.0)

Q.3

Based on the above findings, do you think ischaemic bowel is likely and how would this change your management plan?

The patient’s condition responds rapidly with the intravenous fluid replacement and after 2 litres of intravenous fluid her blood pressure is 120/85 mmHg. The chest and abdominal X-rays do not show any abnormalities.

Q.4

What further investigation should now be undertaken?

A CT scan of the abdomen is performed. Two representative films are shown in Figures 16.1 and 16.2.

image

Figure 16.1

image

Figure 16.2

Q.5

What do the above CT images show and what management is most appropriate?

Q.6

What are the most common infective organisms involved in this disease process and what antibiotics would you use to treat such infection?

The patient continues to improve and it is decided to pursue a course of conservative management. After 4 days of intravenous fluids and antibiotics her condition is judged satisfactory for her to be discharged home.

Q.7

How would you manage this patient after discharge and what advice would you give with respect to long-term management?

Q.8

What is likely to happen to a patient in the long term after presenting with an attack of acute diverticulitis. What complications may occur in the future?

Answers

A.1 The story fits well for acute diverticulitis. Other gastrointestinal problems to consider include intestinal obstruction and appendicitis. Pancreatitis may sometimes present with a similar clinical picture. Urinary infection, vascular and gynaecological problems must also be considered although with the nausea, vomiting and constipation, they are less likely. The sudden worsening of her pain raises the possibility of perforation – a well-recognized complication of diverticulitis.

A.2 The patient is hypotensive, probably due to dehydration and sepsis. She has a localized peritonitis and this suggests an inflammatory process, perhaps with abscess formation or free perforation. This would all fit for acute diverticulitis with a possible related complication. The initial management plan and investigations should be as follows:

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