Abdominal pain is not an uncommon presentation - but in this case it revealed an unusual diagnosis.
A 43-year-old male arrives in the ED with left lower quadrant pain that started 2 days ago. The pain has been constant and has been getting progressively worse, reaching a rating now of 6/10. He denies radiation of the pain. There are no alleviating or remitting factors. He denies any fever but reports some mild chills. He has had no nausea or vomiting, but he does report a decrease in appetite. He denies any urinary frequency, urgency, or hematuria. No history of kidney stones. His medical and surgical history includes asthma and an open reduction and internal fixation of the left knee. He denies past or current tobacco or drug use. He admits to social alcohol consumption. Vital signs at presentation are blood pressure 129/95 mmHg, heart rate 97 beats/min, respiratory rate 20 breaths/ min, temperature 370 C, and oxygen saturation 97% on room air. On clinical examination, the patient is in moderate discomfort. There is tenderness to the left lower quadrant. There is no guarding or rebound and no costovertebral angle tenderness. The rest of the physical exam is within normal limits.
The patient is initially treated with IV fluids and 4 mg of morphine. Laboratory evaluation includes a complete blood count, complete metabolic profile, and urinalysis. The results of the CBC reveal a white blood cell count of 16.12 x 109 /L and urinalysis was positive for hemoglobinuria; the CMP was unremarkable. A CT of the abdomen and pelvis without contrast reveals acute uncomplicated acute diverticulitis of the sigmoid colon as well as a 2.3 mm stone in the left distal ureter at the ureterovesicular junction.
Abdominal pain is the leading reason for ED visits in the U.S. for both females and males, according to the Centers for Disease Control and Prevention. Abdominal pain accounted for almost 8% of ED visits in 2013.
The use of medical imaging for overall abdominal pain diagnosis has increased from 20% in 2000 to 44% in 2008.3 In a study published by Choy and Yoon in 2013, 50% of the patients with abdominal pain had intra-abdominal pathology on CT tnat could explain their abdominal pain. Intra-abdominal pathology correlated with age greater than 35 and leukocytosis.2
Causes of left lower quadrant pain in males can be vast, including vascular, gastrointestinal, genitourinary, abdominal wall pathologies. Guided by strong clinical correlation, a CT scan is the preferred modality to evaluate LLQ pain in a male patient when suspicion for diverticulitis or obstructing urological pathology is high.
Diverticulitis is a complication of diverticulosis, a condition when small pouches form in the wall of the colon from herniation of the colonic mucosa and submucosa. Many patients with diverticulosis will be asymptomatic and only be diagnosed when they have a colonoscopy or an abdominal CT. Diverticulosis can be silent, or it can be expressed with diverticular bleeding or inflammation as in diverticulitis.8
Diverticulosis occurs in 5-10% of people by 45 years of age, and 10-20% of people diagnosed with diverticulosis will end up developing diverticulitis.7 The prevalence of diverticulitis increases with age, and its incidence is higher in developed countries than developing countries.
The exact pathophysiology of how diverticula develop remains uncertain. Numerous theories exist, combining aspects of diet, motility, the microbiome, and inflammatory factors. The archaic theory of diverticulitis resulting from the consumption of high fat or fiber-lacking foods which along with stool lodges in diverticula, in turn causing trauma, ischemia and focal perforation.8 The most typical presenting symptoms and findings are left sided abdominal pain, fever, rigors, leukocytosis and elevated C-reactive protein.
CT scans have reported around 100% sensitivity in the diagnosis of diverticulitis. CT scan of the abdomen and pelvis is the preferred imaging modality to diagnose the disease, evaluate its severity, and screen for associated complications.
In the U.S., the severity of diverticulitis can be assessed by the Buckley or Hinchey classification system.7,8 Diverticulitis can be uncomplicated or complicated. In uncomplicated diverticulitis with no sign of systemic toxicity, patients are treated as outpatients with antibiotics. In the complicated diverticulitis cases, patients can develop abscesses, peritonitis, fistulas, or obstructions. In these complicated cases, patients should be hospitalized and treated with IV antibiotics, bowel rest, and/or surgery.8
Urolithiasis has a prevalence of 12% in men and 6% in women and accounts for 1.0% to 1.7% of annual ED visits.3, 4 Urinary stones are formed in the kidney and continue their course down the ureter. Around 75% of the stones are made of calcium oxalate and calcium phosphate, which results from hypercalciuria. Hyperexcretion of calcium is linked to disease states such as hyperparathyroidism and sarcoidosis, dietary increase in calcium intake, and increased gut absorption of calcium.
Uric acid stones account for 6% of renal stones and are the result of hyperexcretion of uric acid from conditions such as gout, malignancy, insulin resistance, and kidney insufficiency.
Fifteen percent of stones are made of magnesium-ammonium-phosphate, caused by urinary tract infection with urea-splitting organisms such as Proteus, Pseudomonas, and Klebsiella species.
Cystine stones, caused by a condition where there is a decrease in reabsorption of cystine, make up only 2% of all stones.6
Ureteral stones usually present with sudden onset of severe colicky flank pain, which can be associated with nausea, vomiting and hematuria. Non-contrast CT scan has become the imaging of choice for detecting ureteral stones with both specificity and sensitivity of approximately 95%. 6
Management of ureterolithiasis in the ED consists of NSAIDs for pain, antiemetics, and IV fluids. Criteria for admission include acute kidney injury, fever, bilateral obstructing stones or intractable vomiting or pain. Stones less than 5mm typically pass spontaneously, although studies have shown that use of tamsulosin can facilitate the expulsion.4 The greatest benefit from alpha blockade has been shown for stones between 5-10 mm. Extra-corporeal shock-wave lithotripsy or ureteroscopy is indicated for stones bigger than 10 mm.3
No cases of synchronous obstructive ureterolithiasis and acute diverticulitis have ever been reported in the medical literature. However, a case of synchronous obstructive ureterolithiasis and acute appendicitis was reported in 2012. The patient was a 47-year-old male with previous episodes of nephrolithiasis who presented with umbilical abdominal pain for 3 days.10 The symptoms of the patient in our case were recognized promptly; however, it was unclear if the patient had acute diverticulitis or obstructive uropathy. The correct diagnostic imaging modality was utilized, and appropriate laboratory tests were ordered. Considering the patient was clinically stable, had no significant medical comorbidities or impaired immunity, and was nontoxic appearing, he was discharged home to be treated as an outpatient with ciprofloxacin and metronidazole. He was advised to follow up with urology within 10 days, and strict, detailed instructions to return to ED were provided.
1. Centers for Disease Control and Prevention. Table 10. Ten leading principal for emergency department visits, by patient age and sex: United States, 2013.
2. Choy T, Yoon HC. Computed Tomography Abdomen/Pelvis in the Emergency Department: Can Clinical Parameters Guide the Appropriate Use of Imaging? Hawaii J Med Public Health. 2013;72(9 Suppl 4):42.
3. Bodmer NA, Thakrar KH. Evaluating the Patient with Left Lower Quadrant Abdominal Pain. Radiol Clin North Am. 2015;53(6):1171-188.
4. Bultitude M, Rees J. Management of Renal Colic. BMJ. 2012;345:e5499.
5. Strong SA. Acute Diverticulitis. J Clin Gastroenterol. 2011;45(4):62-69.
6. Sidhu R, Bhatt S, Dogra VS. Renal Colic. Ultrasound Clin. 2008;3(1):159-170.
7. Hammond NA, Nikolaidis P, Miller FH. Left Lower-Quadrant Pain: Guidelines from the American College of Radiology Appropriateness Criteria. Am Fam Physician. 2010;82(7):766-770. Web. 06 May 2017.
8. Feuerstein JD, Falchuk KR. Diverticulosis and Diverticulitis. Mayo Clinic Proceedings. 2016;91(8):1094-1104.
9. Bader MJ, Eisner B, Porpiglia F, Preminger GM, Tiselius HG. Contemporary Management of Ureteral Stones. Eur Urol. 2012;61(4):764-772.
10. Spiel A, Cowden W. Synchronous Obstructive Ureterolithiasis and Acute Appendicitis. J Surg Case Rep. 2012;2012(9):16.