Patient details
- Name
- Mr K.H.
- Age / sex
- 62-year-old man
- Occupation
- Shopkeeper
- Marital status
- Married, lives with his wife
- Admitted
- Emergency department, 19:15
- Clerked
- Surgical ward, 20:30
- Source
- Patient himself, reliable
- Referred by
- Family doctor
Presenting complaint
“Pain low down on the left side of my tummy for three days.”
History of presenting complaint
Mr K.H. was well until three days before admission, when he noticed a vague discomfort across the lower abdomen. Within a day it settled in the lower left side, where it has stayed. The pain came on gradually and is a constant ache, now 7 out of 10, which does not move anywhere else. It is worse on walking, coughing and going over bumps in the car, is not relieved by opening his bowels or passing wind, and is eased by paracetamol for only an hour or two. He has felt feverish for two days and measured 38.2 °C at home, without rigors. He feels nauseated and has lost his appetite but has not vomited. He normally opens his bowels once a day and tends towards hard stools; he has been constipated for four days, last passing a small hard stool yesterday, and is still passing wind. He had one similar but milder attack of left-sided pain about a year ago, which settled in two days without treatment, and he has never had a colonoscopy. He has seen no blood or mucus in the stool and no black stools. Before this illness there was no change in his bowel habit, no feeling of incomplete emptying and no weight loss, and his appetite was normal. He has no abdominal swelling. He has not noticed air bubbles or debris in the urine and has not had repeated urine infections. He has no burning on passing urine, no blood in the urine and no pain running from the loin to the groin. He has no lump in the groin and no pain or swelling in the scrotum. He has had no diarrhoea, no recent antibiotics and no recent travel, and he has no back pain and no known aneurysm.
Past medical history
Type 2 diabetes for eight years. Hypertension for five years. No heart disease, no stroke, no kidney disease.
Past surgical history
Open repair of a right inguinal hernia with mesh in 2015 under spinal anaesthesia, with no complications.
Drugs and allergies
Metformin 1 g twice daily. Amlodipine 5 mg once daily. Ibuprofen two or three times a week for knee pain. No anticoagulants and no steroids.
No known drug allergies.
Family history
No family history of bowel cancer, polyps or inflammatory bowel disease. His father died of a heart attack at 70.
Social history
Smokes 20 cigarettes a day for 35 years (35 pack-years). No alcohol. Diet low in fruit and vegetables. Sits for most of the working day. Independent in all daily activities.
Last ate at 13:00 today; last drank water at 18:00.
Systems review
Cardiovascular, respiratory, neurological and musculoskeletal systems: no symptoms other than chronic knee pain.
General examination
A man who looks uncomfortable, lying still in bed. Alert and orientated. Not pale, not jaundiced. Tongue slightly dry. Weight 92 kg, height 174 cm, body mass index 30.
Hands warm, capillary refill under two seconds. No enlarged lymph nodes in the neck, including the left supraclavicular fossa. No ankle swelling.
Abdominal examination
Inspection
Abdomen full but not distended. It moves with respiration. Healed scar in the right groin. No visible peristalsis and no visible masses.
Palpation
Tenderness with guarding and rebound, confined to the left iliac fossa. No definite mass felt, though deep palpation was limited by guarding. The rest of the abdomen is soft and not tender; no generalised rigidity. Liver, spleen and kidneys not palpable. No renal angle tenderness. No pulsatile, expansile mass.
Percussion
Percussion tenderness in the left iliac fossa. Liver dullness preserved. No shifting dullness.
Auscultation
Bowel sounds present and normal.
Groins and external genitalia
No cough impulse at either inguinal or femoral orifice. Right hernia repair intact. Both testes normal in position, size and consistency, and not tender.
Rectal examination
Performed with consent and a chaperone. Perianal skin normal. Normal anal tone. Soft brown stool in the rectum. No mass felt. Tenderness high on the left side. Prostate smooth and not enlarged. No blood or mucus on the glove.
Other systems
Chest: equal expansion, normal breath sounds, a few scattered wheezes, no crackles.
Heart: first and second heart sounds normal, no murmurs.
Legs: femoral and foot pulses present and equal. Calves soft and not tender.
Summary
Provisional diagnosis
Acute sigmoid diverticulitis, clinically without generalised peritonitis.
Initial plan
- Clear fluids only for now, intravenous fluids, analgesia avoiding anti-inflammatory drugs.
- Bloods: full blood count, C-reactive protein, urea, creatinine and electrolytes, glucose. Urine dipstick.
- CT scan of the abdomen and pelvis with intravenous contrast, after checking the creatinine and with attention to his metformin.
- Antibiotics according to hospital protocol. Regular glucose monitoring. Prevention of leg vein thrombosis.
- Senior surgical review. Colonoscopy six to eight weeks after recovery to exclude cancer.
Differential diagnosis of left iliac fossa pain
Group the causes by organ, start with the most likely, and for each one give the feature that supports or excludes it in your patient.
| Diagnosis | Points to it in the history | Points to it on examination | In this patient |
|---|---|---|---|
| Colon | |||
| Acute diverticulitis | Older patient, constant pain for days, fever, constipation or loose stools, earlier similar attacks | Fever, local tenderness and guarding, sometimes a tender mass | Most likely |
| Diverticular abscess or perforation | Pain getting worse and spreading, swinging fever, rigors | Fast pulse, tender mass, or generalised rigidity | No sepsis, no rigidity; CT decides |
| Cancer of the sigmoid colon | Change in bowel habit for weeks, rectal bleeding, weight loss, anaemia symptoms | Pallor, hard mass, mass or blood on rectal examination | No red flags, but never had a colonoscopy |
| Sigmoid volvulus | Elderly or bedbound, sudden colicky pain, no stool or wind at all, great distension | Drum-like distended abdomen, empty rectum | Not distended, passing wind |
| Ischaemic colitis | Sudden cramping pain followed by bloody diarrhoea; vascular disease, atrial fibrillation | Left-sided tenderness, blood on the glove | No bleeding |
| Ulcerative or infective colitis | Bloody diarrhoea with mucus, urgency; travel, antibiotics, contacts | Mild left-sided tenderness, blood and mucus on the glove | No diarrhoea |
| Constipation | Infrequent hard stools, straining, no fever | No fever, soft abdomen, loaded rectum | Does not explain fever or guarding |
| Urinary tract | |||
| Left ureteric colic | Sudden severe colicky pain from loin to groin, blood in urine, restless patient | Patient cannot lie still; little abdominal tenderness | Pain constant, patient lies still |
| Pyelonephritis or urine infection | Burning urine, frequency, loin pain, rigors | Renal angle or suprapubic tenderness | No urinary symptoms; dipstick to confirm |
| Groin and scrotum | |||
| Strangulated inguinal or femoral hernia | Known groin lump that has become painful and will not go back; vomiting | Tense, tender, irreducible lump with no cough impulse | Orifices normal |
| Testicular torsion or epididymo-orchitis | Scrotal pain, sudden in torsion; urinary symptoms or discharge in infection | Tender swollen testis, high-lying in torsion | Testes normal |
| Vascular | |||
| Leaking aortic or iliac aneurysm | Older smoker, sudden abdominal or back pain, collapse | Low blood pressure, pulsatile expansile mass | Stable, no mass; CT will show |
| In women | |||
| Ectopic pregnancy | Missed period, vaginal bleeding, shoulder tip pain, fainting | Pallor, fast pulse, low blood pressure | Pregnancy test in every woman of childbearing age |
| Ovarian torsion or ruptured cyst | Sudden severe one-sided pain with vomiting, often mid-cycle | Tender adnexal mass | Not applicable |
| Pelvic inflammatory disease | Pain on both sides, discharge, pain with intercourse, fever | Tenderness low on both sides | Not applicable |
| Others | |||
| Psoas abscess | Fever, back or hip pain, limp | Hip held flexed, pain on extending the hip | Hip moves freely |
| Rectus sheath haematoma | Sudden pain after coughing or straining, patient on anticoagulants | Tender mass in the abdominal wall that stays when the muscles tense | No anticoagulants |
Clinical signs related to this case
The signs you should look for in any patient with left iliac fossa pain. For each one, know how to elicit it and what a positive result means.
| Sign | How to elicit it, or what you see | What it means |
|---|---|---|
| Peritoneal irritation | ||
| Guarding | The muscles tighten under your hand when you press | Inflammation beneath that area. Local guarding fits uncomplicated diverticulitis. |
| Rigidity | The whole abdominal wall is board-hard without being touched | Generalised peritonitis: free perforation. A surgical emergency. |
| Rebound and percussion tenderness | Pain when the hand is released, or on gentle percussion, or on coughing | The peritoneum is inflamed |
| Tender mass in the left iliac fossa | A fixed, ill-defined, tender swelling | Inflammatory mass or abscess. A hard, non-tender mass suggests cancer. |
| Obstruction and volvulus | ||
| Distension with a drum-like note | Swollen abdomen, resonant on percussion | Gas-filled bowel: large bowel obstruction or sigmoid volvulus |
| Visible peristalsis | Waves of bowel movement seen through a thin abdominal wall | Bowel working against an obstruction |
| Tinkling bowel sounds | High-pitched, frequent sounds | Mechanical obstruction. A silent abdomen suggests peritonitis or ileus. |
| Empty, ballooned rectum | No stool and a wide rectum on rectal examination | Obstruction higher up |
| Rectal examination | ||
| Mass on the finger | Hard, irregular, fixed lump | Rectal cancer, or a pelvic tumour felt through the wall |
| Blood or mucus on the glove | Look at the glove every time | Fresh blood: bleeding from the lower bowel. With mucus: colitis or cancer. |
| Boggy tender swelling in front | Soft, tender bulge felt through the front wall of the rectum | Pelvic abscess |
| Groin and scrotum | ||
| Cough impulse | A groin swelling expands and pushes against the hand on coughing | Hernia. Absent, with a tense tender lump, when the hernia is strangulated. |
| Absent cremasteric reflex | Stroking the inner thigh fails to lift the testis on that side | Testicular torsion |
| Signs that point away from the colon | ||
| Pulsatile, expansile mass | Two hands placed either side of the mass are pushed apart with each beat | Aortic aneurysm |
| Renal angle tenderness | Pain on firm pressure between the twelfth rib and the spine | Pyelonephritis or an obstructed kidney |
| Psoas sign | Pain on passive extension of the hip, patient lying on the opposite side | Psoas abscess, or inflammation lying on the psoas muscle |
Teaching case. The patient is fictional and written to illustrate format and reasoning. Local protocols decide investigation and treatment.