Differential Diagnosis

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In patients over the age of 40 presenting with complaints of abdominal pain, a change in bowel habits, and urinary symptoms, a diagnosis of colonic diverticulitis should be entertained. These symptoms, however, are nonspecific, and a number of pathologic entities may present with similar signs and symptoms ( Table.. ..7.7.-2.). Some of the most important are discussed below.

Symptoms of irritable bowel syndrome include diffuse crampy or colicky abdominal pain, brought on by meals or emotional upset. The patients may also describe a bloated or distended sensation in the abdomen. The symptoms are usually intermittent and chronic. The passage of flatus or a bowel movement may bring relief. The disease is characterized by alternating bouts of constipation and diarrhea. On physical examination, the patient is afebrile and a cordlike mass may be appreciated in the left lower quadrant corresponding to the sigmoid colon. Signs of localized or generalized peritonitis are not seen. Laboratory studies are normal.

Patients who have colon carcinoma may present with a change in bowel habits, either diarrhea or constipation, and/or abdominal pain that can mimic symptoms of diverticular disease. There may be blood mixed with the patient's stools, and weight loss. Physical examination may reveal a palpable mass, usually nontender. Fever and chills are less common, and laboratory studies may demonstrate anemia without evidence of leukocytosis. An acute abdominal series may demonstrate findings of colonic obstruction. This can be produced by an inflamed diverticula or a carcinoma in an area of the bowel with underlying diverticulosis. Fiberoptic colonoscopy can be useful in differentiating diverticular disease from carcinoma.

Pelvic inflammatory disease may present with abdominal pain, fever, and leukocytosis. The disease is usually found in young women. A careful pelvic examination should be carried out in all female patients with lower abdominal pain. A history of irregular menses and the finding of vaginal discharge should aid in the diagnosis.

Ischemic colitis can present with a broad range of clinical manifestations. Mild transient ischemia may result in mucosal sloughing and painless rectal bleeding. If the disease progresses to gangrene, the patient develops severe abdominal pain and peritonitis. Pain may be out of proportion to physical findings. A plain film of the abdomen may reveal thumbprinting in the region of the involved colonic segment. In more advanced cases, there may be gas within the bowel wall, or, if perforation has occurred, free air in the abdomen. Cautious endoscopic evaluation and contrast x-ray studies are helpful in distinguishing ischemic colitis from diverticulitis.

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