LIF pain Flashcards
Mrs Hamilton is a 76-year-old lady who presents at her local accident and emergency (A&E) with left iliac fossa (LIF) pain.
What is your differential diagnosis for LIF pain? As we have done for previous presentations, try to think anatomically of what structures might give you pain in the LIF. Try to prioritize into those conditions that are most likely (or most common), those that you must exclude, and the remainder.
Acute diverticulitis† Constipation Inflammatory bowel disease (IBD) Ischaemic colitis Pseudomembranous colitis‡ Leaking abdominal aortic aneurysm (AAA) Locally perforated sigmoid carcinoma Urinary tract infection Ureteric colic Pyelonephritis Irritable bowel syndrome (IBS) Shingles Rectus sheath haematoma Diabetic ketoacidosis
† A quick note on nomenclature. Diverticulosis refers to the presence of diverticula in the bowel (which may be asymptomatic). Diverticular disease is symptomatic diverticulosis, which can manifest as painless bleeding, altered bowel habit, or painful inflammation (acute diverticulitis).
‡ Pseudomembranous colitis is an acute inflammatory condition of the bowel that is usually, but not always, caused by Clostridium difficile.
If Mrs Hamilton had been pre-menopausal would there have been any other diagnoses to consider?
There are a number of gynaecological pathologies that can cause acute LIF pain. Some, such as ectopic pregnancy, mittelschmerz (mid-cycle pain), or haemorrhage into a functional ovarian cyst, can only occur in menstruating women. Others, such as pelvic inflammatory disease or torsion/rupture of an ovarian cyst, are far more likely to be seen in women younger than Mrs Hamilton, but can be kept in mind as rare differentials for someone of her age.
s there any pathology peculiar to males that may cause LIF pain?
Testicular torsion can cause referred pain to either the left or right iliac fossa and tends to occur in boys and young men. Thus, don’t forget to examine the testes.
What questions would you like to ask Mrs Hamilton about the pain in order to help narrow your differential diagnosis?
Site: Where is the pain, and has it always been there? Pain that is initially poorly localized, midline, and colicky but which then migrates to the LIF and becomes constant is highly suggestive of acute diverticulitis (akin to left-sided appendi- citis). Pain that migrates down the left flank and iliac fossa is more consistent with the migration of a ureteric stone.
Onset: Gradual or sudden? Sudden onset of pain is suggestive of perforation of a viscus, or of acute haemorrhage (into an ovarian cyst) or torsion (of an ovary or testis).
Character: Is the pain colicky or constant? Is it sharp or dull? Acute diverticulitis is often preceded by colicky midline pain. Ureteric calculi may result in colicky pain. Established diverticulitis, and the other differential diagnoses from our list would all produce constant abdominal pain. Sharp pain is most suggestive of haemorrhage, perforation, or torsion.
Radiation: Does the pain radiate to the groin (typical of ureteric pain)?
Alleviating factors: Does anything make the pain better? Discomfort due to IBS may be relieved by defecation. Peritonitic patients will be most comfortable when lying still.
Timing: How long has the pain been present? Have there been any previous similar episodes? Patients with IBS may have suffered from abdominal discom- fort for many months or years. Patients with acute diverticulitis often give a history of 2–3 days of LIF pain, and may have had a previous episode.
Exacerbating factors: Does anything make the pain worse? Patients with peri- tonitis (e.g. due to colonic perforation) are very sensitive to motion and may mention that the car journey to the hospital was painful (i.e. every time they hit a bump).
Severity: How severe is the pain (e.g. on a scale of 1–10)? Ureteric colic is excru- ciatingly painful, as is colonic perforation secondary to diverticulitis or a sigmoid carcinoma.
Mrs Hamilton’s pain started about 24 hours ago. She woke in the morning with ‘vague stomach cramps’. By mid-morning she was suffering from constant pain in her LIF. She took some paracetamol at home, but this did not relieve the pain, which she reports as dull but 7/10 intensity. The pain does not radiate.
Having characterized the pain, what other symptoms should you enquire about?
• Nausea and vomiting? Nausea and, to a lesser extent, vomiting, are seen with acute diverticulitis. They may also accompany pelvic inflammatory disease.
• Fever? Indicating an underlying infective or inflammatory disease such as acute diverticulitis.
• Change of bowel habit? A relatively non-specific symptom of most of the colonic diseases in our differential. IBS, diverticular disease, IBD, and colorec- tal carcinoma may all result in prolonged changes in bowel habit.
• Rectal bleeding? Overt rectal bleeding may be seen with acute diverticulitis, but is more likely to be seen in the context of bloody diarrhoea with ulcerative colitis, pseudomembranous colitis, ischaemic colitis, or colorectal carcinoma.
• Bloating? This is a characteristic feature of IBS.
• Weight loss? Although acute pain is an atypical presentation of colorectal car-
cinoma, a history of unintentional weight loss may raise your suspicions.
• Gynaecologicalsymptoms?Newvaginaldischargeand/orpainduringsex(dys- pareunia) are consistent with pelvic inflammatory disease. In women who are menstruating, ask about the timing of the last menstrual period, regularity of periods, painful periods, and whether there is any possibility that the woman could be pregnant.
Are there any particular medicines to look out for in the drug history?
The most important class of drugs to be aware of are steroids as these can dampen the inflammatory response, thus masking signs and symptoms. Bear in mind that patients taking steroids may be more ill than they appear by clinical examination. Recent use of antibiotics (or proton-pump inhibitors) may raise your suspicions of pseudomembranous colitis (Clostridium difficile colitis) in patients presenting with LIF pain and diarrhoea.
On further questioning, Mrs Hamilton explains that she has felt nauseated since this morning, but has not actually vomited. She feels feverish. She has not had any diarrhoea or felt constipated, and has not passed any blood per rectum. There are no gynaecological symptoms to note. She says that she is otherwise fit and well, and that her weight has not changed recently. She takes no medications, does not smoke, and enjoys an occasional glass of wine.
Mrs Hamilton reports that she suffered from a similar pain last year, and that her GP had then advised her to drink lots of clear fluids and had prescribed her antibiotics and painkillers. However, Mrs Hamilton feels worse on this occasion, and thought that she should go to hospital instead of her GP.
What in particular will you look for when examining Mrs Hamilton?
- How unwell is Mrs Hamilton? Check her basic observations: HR, BP, T, RR and Sats.
- Does she appear to have generalized peritonitis? Is she lying very still, taking shallow breaths, and looking pale?
- Is the patient writhing in pain, unable to keep still? This is typical for ureteric colic.
Describe Mrs.Hamilton’s abdominal exam
- You should examine the abdomen for any focal tenderness. Typically, uncomplicated acute diverticulitis presents with local tenderness and/or guarding.
- Does the patient have generalized peritonitis (tender, rigid abdomen with absent bowel sounds)? If so, you should suspect perforation of a colonic diver- ticulum, sigmoid carcinoma, or AAA.
- Are there any masses? A mass may be palpable in the LIF in patients with acute diverticulitis, even in the absence of a local abscess. A sigmoid carcin- oma may also be palpable. A central, laterally pulsatile mass is an AAA until proven otherwise.
Describe Mrs.Hamilton’s rectal and vaginale examinations
Rectal examination
• It may be possible to detect a pelvic abscess in patients with acute diverticuli- tis, and may also be possible to palpate a rectal malignancy.
Vaginal examination
• This is not indicated in Mrs Hamilton, but would be required in women pre- senting with LIF pain and new vaginal discharge, as cervical motion tender- ness would lend weight to a diagnosis of pelvic inflammatory disease.
Mrs Hamilton is febrile (38.2°C) and tachycardic (113 bpm regular), and looks flushed. Her blood pres- sure is 135/72 and her reopiratory rate is 21/min. She does not appear to have generalized peritonitis. Her LIF is tender to palpation, but the rest of the abdomen is soft and non-tender. There is no guarding or percussion tenderness. No masses are palpable, there is no organomegaly, and no palpable AAA. Bowel sounds are present. A digital rectal examination is unremarkable.
Which blood tests would you like to request?
There are very few blood tests that are actually informative or necessary given this history:
• Full blood count (FBC): the white cell count may be elevated in response to any inflammatory condition (e.g. acute diverticulitis, pseudomembranous colitis).
• Urea and electrolytes (U&Es): useful for establishing the baseline electrolyte status of the patient (remembering that a number of the diagnoses on our dif- ferential will require intravenous (IV) fluids and/or surgery).
Blood tests are performed. The white cell count (WCC) is 14.1 × 109 cells/L (neutrophils 11.2 × 109 cells/L), and U&Es are unremarkable.
In light of the history, examination, and first-line investigations, what is the most likely diagnosis?
It is most likely that Mrs Hamilton has acute diverticulitis. She is an elderly patient with constant LIF pain, preceded by vague midline colicky pain, which is associated with nausea and fever. Examination confirms the LIF tenderness and shows no evidence of peritonism or an abscess. The leucocytosis confirms the underlying inflammatory response. Furthermore, there is a suggestion from the history that Mrs Hamilton has suffered from a previous episode of acute diver- ticulitis that was treated in the community.
Which imaging studies may be requested in the acute phase?
Mrs Hamilton appears clinically to have relatively mild diverticulitis, and there are some surgeons who would start empirical medical therapy without requesting any further imaging in the acute phase. However, a radiologically confirmed diagno- sis is useful for determining whether surgery is indicated (see later in this case), and is also invaluable in more severely unwell patients, in those refractory to treatment, or those with a different history:
• Abdominal computed tomography (CT) with contrast: this is the imaging modality of choice for diagnosing acute diverticulitis and planning future elective surgery. If there is a suspicion of an abscess complicating acute diver- ticulitis, or if the patient is seriously ill, clinically deteriorates, or the diagnosis is unclear, then abdominal CT is also invaluable.
• Erect chest radiograph: request this if there is any clinical suspicion of a per- forated viscus, looking for air under the diaphragm.
• Abdominal radiograph: useful for ruling out bowel obstruction if this is clinically suspected.
If Mrs Hamilton had been pre-menopausal are there any other imaging modalities that you would request to investigate her LIF pain?
Transabdominal ± transvaginal ultrasound are particularly useful investiga- tions in young female patients, where the differential diagnosis is broadened by gynaecological pathology.
Could Mrs Hamilton have had a colonoscopy or double-contrast barium enema to confirm the diagnosis in the acute phase of her illness?
Mrs Hamilton should not have had either investigation in the acute phase. Colon- oscopy and double contrast barium enema are contraindicated in the acute setting as there is a risk of perforating the acutely inflamed colon.
How should Mrs Hamilton be managed in the acute phase?
Mrs Hamilton should be treated as follows:
• Analgesia
• Bowel rest: by clear fluids only
• IV fluids: if Mrs Hamilton is unable to maintain a sufficient oral intake
• Antibiotics: to cover Gram-negative bacteria and anaerobes (e.g. co-amoxiclav plus metronidazole, but consult local guidelines)
• Monitor: if symptoms do not improve within 48–72 hours, further investi- gation is required to establish whether an abscess is present, or whether the initial diagnosis was flawed.
