Acute abdominal pain, fever may signify diverticulitis

In older patients who complain of fever and lower abdominal pain, consider diverticulitis, especially if the patient has a previous diagnosis of diverticulosis.

Acute abdominal pain and fever could signify diverticulitis
Acute abdominal pain and fever could signify diverticulitis

Regardless of our specialty, our job is to be aware of all the possible illnesses that a patient may be experiencing. It is our duty as clinicians to assist in having these findings assessed by the appropriate providers. Recently, I noticed that several of my patients have been diagnosed with diverticulosis and diverticulitis.

A patient of mine, aged 75 years, came in for a routine office visit. He didn't look as upbeat as usual, so I asked what was causing him to seem so down. The patient noted that he was having some lower abdominal pain. He reported the pain wasn't severe, but “just enough to be irritating.” The patient also mentioned he sometimes felt nauseous and constipated.

I palpated his abdomen in an effort to consider differential diagnoses, which included carcinoma and Crohn disease. The seemed to be most tender in the left lower quadrant. A note in the patient's chart mentioned a previous diagnosis of diverticulosis, which made me suspicious. I sent him to see his primary-care provider that afternoon, and later, my diagnosis was confirmed. The patient had developed diverticulitis.

Approximately 30% of patients aged older than 60 years and more than 50% aged older than 80 years will develop diverticulosis, and fewer than 5% of these patients develop complications of diverticulitis.

Many patients are unaware that they have diverticulitis until they are being evaluated for something else. Many times, the condition is found incidentally. Although originally considered to occur due to a lack of fiber in the diet, the etiology of diverticulosis is not clear at present.

Diverticulitis occurs when the diverticuli become inflamed or infected. Patients may complain of constipation or loose stools and may develop low-grade fever. Nausea and vomiting frequently occur. There may be complaints of blood in the stool.

Palpation will often reveal pain in the left lower quadrant, but pain can be experienced in other areas as well. Lab work will show a mild-to-moderate leukocytosis. Perforation can occur, but patients will usually present with greater symptoms including peritoneal signs.

Patients are usually treated with a clear liquid diet and a course of antibiotics, although researchers from the University of Michigan, who did a systematic review of literature, proposed we may be over-treating the disease. The research suggests the need for aggressive treatment with antibiotics and surgery in uncomplicated disease is unwarranted.

A computed tomography (CT) scan of the abdomen can assess for severity of disease. Once the acute phase has passed, the patient should see a gastroenterologist for follow-up with colonoscopy or barium enema to exclude neoplasm.

Endoscopy and colonography are contraindicated in the acute phase. Surgical consultation should only be considered in those with severe disease. The good news for patients is that fewer than 5% will have more than two recurrences.

In older patients who complain of fever and lower abdominal pain, consider diverticulitis, especially if the patient has a previous diagnosis of diverticulosis.

Sharon M. O'Brien, MPAS, PA-C, is a practicing clinician with an interest in helping patients understand the importance of sleep hygiene and the impact of sleep on health.

References

  1. Papadakis M et al. Current Medical Diagnosis and Treatment 2015. Chapter 15. "Gastrointestinal Disorders" p. 647-650.
  2. Morris AM et al. JAMA. 2014; doi:10.1001/jama.2013.282025.
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