Abdominal Pain

Stabbing Abdominal Pain in a 34-Year-Old Woman

Alan Lucerna, DO
James Espinosa, MD
Nicholas Tomasello, DO
Victor Scali, DO
Volume 57 - Issue 2 - February 2017

Authors:

Nicholas Tomasello, DO
Rowan University School of Osteopathic Medicine, Stratford, New Jersey

Alan Lucerna, DO
Rowan University School of Osteopathic Medicine, Stratford, New Jersey

Victor Scali, DO
Rowan University School of Osteopathic Medicine, Stratford, New Jersey

James Espinosa, MD
Rowan University School of Osteopathic Medicine, Stratford, New Jersey

 

Citation: Tomasello N, Lucerna A, Scali V, Espinosa J. Small bowel diverticulitis. Consultant. 2017;57(2):131-132.

 

A previously healthy 34-year-old woman with no past surgical history presented to the emergency department (ED) reporting abdominal pain.

History and physical examination. The patient stated that she had been in her usual state of health but while resting overnight had developed discomfort localized to the periumbilical region, which she described as sharp and stabbing. She denied radiation of pain elsewhere. The pain was not associated with nor aggravated by meals; however, she did admit to exacerbation of pain with any body movement, relieved by lying completely still in her bed.

She denied any associated fevers, chills, chest pain, nausea, vomiting, constipation, diarrhea, hematochezia, melena, or hematemesis. She denied any excessive use of nonsteroidal anti-inflammatory drugs.

The patient was afebrile at presentation, and her vital signs were stable.

Diagnostic tests. Laboratory data were significant for an elevated white blood cell count of 14,700/µL but were otherwise unremarkable. Computed tomography (CT) scanning of the abdomen and pelvis with intravenous and oral contrast (Figure) revealed moderate to extensive inflammatory reaction involving the left upper quadrant, consistent with jejunal diverticulitis with contained microperforation.

Small Bowel Diverticulitis Figure

The patient was started on intravenous ciprofloxacin and metronidazole and was admitted to the surgical service for further general surgery and gastroenterology evaluation. The patient was maintained on intravenous antibiotics.

Outcome of the case. The remainder of her hospitalization was uncomplicated, and the patient was discharged 3 days later following clinical improvement in her symptoms.

Discussion. Abdominal pain is one of the most common presenting complaints in emergency medicine, comprising 7% to 11% of all ED visits.1,2 The differential diagnosis for cases of  undifferentiated abdominal pain is vast; left lower quadrant pain alone can manifest with gastrointestinal, urinary, mesenteric, vascular, or musculoskeletal mechanisms.2 Careful evaluation and recognition of less common presentations is therefore important. Diverticular disease, for example, tends to involve the sigmoid colon and presents with tenderness in the left lower quadrant on evaluation in the majority of cases; however, diverticular disease also can involve the small bowel in rare instances,3 such as in our patient’s case.

Diverticulosis and diverticular disease are common causes of abdominal pain, and its incidence is increasing worldwide.3 The mechanism is controversial but is thought to involve acute inflammation of the diverticulum from retained fecal material and fecal microbiota, with resultant abscess formation and microperforation.3 Diverticulitis of the small bowel, however, is an uncommon presentation of diverticular disease, with a prevalence ranging from 0.06% to 1.3%.4 The majority of reported cases describe duodenal involvement (79%), followed by jejuno-ileal involvement (18%).4

Diverticulitis of the small bowel is often missed on conventional CT scans, although magnetic resonance enterography/enteroclysis has improved diagnostic sensitivity. CT imaging characteristically reveals asymmetric focal or segmental small bowel inflammation.5 

Potential complications include perforation with peritonitis, although this is thought to be rare. Surgical management with resection is a consideration in cases of severe disease; however, long-term resolution of symptoms has been described with intravenous antibiotics alone.6

As demonstrated in our patient’s case, small bowel diverticulitis can present with minimal clinical symptoms, and laboratory test results can often be unremarkable.6 Imaging studies along with high clinical suspicion are the mainstays of ED diagnosis, particularly in patients younger than 40 years.

References:

  1. Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012;5:789-797.
  2. 2Bodmer NA, Thakrar KH. Evaluating the patient with left lower quadrant abdominal pain. Radiol Clin North Am. 2015;53(6):1171-1188.
  3. Elisei W, Tursi A. Recent advances in the treatment of colonic diverticular disease and prevention of acute diverticulitis. Ann Gastroenterol. 2016;​29(1):​24-32.
  4. Kassir R, Boueil-Bourlier A, Baccot S, et al. Jejuno-ileal diverticulitis: etiopathogenicity, diagnosis and management. Int J Surg Case Rep. 2015;10:​151-153.
  5. Mansoori B, Delaney CP, Willis JE, et al. Magnetic resonance enterography/enteroclysis in acquired small bowel diverticulitis and small bowel diverticulosis. Eur Radiol. 2016;26(9):2881-2891.
  6. Levack MM, Madariaga ML, Kaafarani HM. Non-operative successful management of a perforated small bowel diverticulum. World J Gastroenterol. 2014;20(48):18477-18479.