Question

A 74-year-old man presents to the emergency room with abdominal pain. He reports acute onset of left lower quadrant abdominal pain and nausea three hours prior to presentation. The pain is severe, constant, and non-radiating. He has had two maroon-colored bowel movements since the pain started. His past medical history is notable for hypertension, hyperlipidemia, atrial fibrillation, insulin-dependent diabetes mellitus, and rheumatoid arthritis. He takes lisinopril, hydrochlorothiazide, atorvastatin, dabigatran, methotrexate. He has a 60 pack-year smoking history and drinks 1-2 beers per day. He admits to missing some of his medications recently because he was on vacation in Hawaii. His last colonoscopy was 4 years ago which showed diverticular disease in the descending colon and multiple sessile polyps in the sigmoid colon which were removed. His temperature is 100.1°F (37.8°C), blood pressure is 145/85 mmHg, pulse is 100/min, and respirations are 20/min. On exam, he has notable abdominal distention and is exquisitely tender to palpation in all four abdominal quadrants. Bowel sounds are absent. Which of the following is the most likely cause of this patient's condition?

a. Cardiac thromboembolism
b. Duodenal compression
c. Perforated intestinal mucosal herniation
d. Paradoxical thromboembolism
e. Splanchnic vasoconstriction

Answer 1

The 74-year-old man's symptoms and medical history suggest the most likely cause of his severe abdominal pain and other symptoms is diverticulitis, a condition where infected and inflamed diverticula cause severe abdominal issues, including pain and blood in the stool.

Step-by-step explanation:

The most likely cause of the 74-year-old man's condition with acute onset of left lower quadrant abdominal pain, nausea, and maroon-colored bowel movements is diverticulitis. This is based on his history of diverticular disease in the descending colon, alongside the symptoms he is presenting, which are classic signs of diverticulitis. Infection and inflammation of the diverticula typically cause severe abdominal pain, fever, and blood in the stool, as described.

The absence of bowel sounds may suggest a complication such as bowel obstruction or perforation, which can occur with severe diverticulitis. Considering his anticoagulation therapy with dabigatran for atrial fibrillation, there is some risk of bleeding complication, although this would not explain the absence of bowel sounds and distention. Hence, the most likely scenario remains diverticulitis with possibly a severe presentation or complication such as perforation.