Lim
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A 65 year-old man develops periumblical pain which then localizes to the right lower quadrant. On physical examination, his temperature is 38.0C(100.5F) rectally, and his bdomen is tender. Which of the following is the most likely diagnosis?
A. Acute appendicitis
B. Diverticulitis
C. Gallstone
D. Pancreatitis
E. Pyelonephritis
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| docarchana
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B - due to age. usually occurs on lt side, but can also occur on rt side.
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| Lim
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yes
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| Leopard
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I think it is appendicitis unless proved otherwise.
Diverticula can occur at any place in the intestine (small & large) but their most common site in old people is Sigmoid colon.
Diverticulitis on the right side is the most possible diagnosis in "Situs inversus".
Other opinions are cordially appreciated.
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| Lim
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yeah...i agree with you.
;qbank expl.
*Diverticulitis is a disease of the elderly, and usually involves the distal colon. However, in severe cases, the diverticula may extend throughout the colon and up to the cecum. Inflammation of a cecal diverticulum can closely mimic acute appendicitis.
*Acute appendicitis is usually a disease of young adults(and sometimes children)
so elderly person comes to ER with periumbilical pain radiating LLQ or RLQ.
first possible diagnosis is Diverticulitis ...maybe..
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| Leopard
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That is right upto some extent.But being practical
The treatment of appendicitis is invariably Operative because obstructive lumen infection does not resolve with antibiotics alon.So it is like a loaded gun in the abdomen which can fire at any time.
On the other hand treatment of diverticulitis is conservative in majority of cases
- Mild cases = outdoor treatment
- Moderate cases = hospitalization with IV antibiotics
- Cases not responding to it = surgical.
The chances of appendicitis becoming gangrenous are extremely high in Elderly.
I hope Kaplan does not like to get rid of old people
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| fox
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I tool feel appendicitis will be a better answer. Is the periumbilical pain, later spreading to the rt lower quad, classical of appendicitis only?
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| Leopard
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fox wrote:
I tool feel appendicitis will be a better answer. Is the periumbilical pain, later spreading to the rt lower quad, classical of appendicitis only?
No ,this is not characteristics of appendicitis only. Diverticulitis of right colon can present in the same way.But clinical diagnosis is always made
- Clinical picture
- Probability
- Graveness of the diseases
A good example is retrosternal pain can be because of many reasons.But in middle aged man retrosternal pain of sudden onset is of "Cardiac origin" unless proved otherwise.
In abdominal pain of the stem question scenario, Leopard thinks that this diverticulitis (while in fact it is appendicitis) and puts on antibiotics and sends him home then result is obvious "Disaster"
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| rashmi verma
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I think, answer will be appencitis, history is suggestive, m. imp SITE, as taught in med school, think of common things first,
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| new_n_lost
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this is wht i found intersting although Appendicitis although a disease of the young but is the rising cause of ED Abdominal pain Presentation. The following is a abstract from the article http://www.emedicine.com/emerg/topic931.htm Appendicitis - Appendicitis is a less common cause of abdominal pain in elderly patients than in younger patients, but the incidence among elderly patients appears to be rising. Only approximately 10% of cases of acute appendicitis occur in patients older than 60 years, whereas one half of all deaths from appendicitis occur in this age group.
The rate of perforation in elderly patients is approximately 50%, 5 times higher than in younger adults. This is largely because 75% of elderly patients wait more than 24 hours to seek medical attention.
The diagnosis can be difficult to make, since more than one half of patients in this age group do not present with fever or leukocytosis. Further confusing the picture, approximately one third do not localize pain to the right lower quadrant, and one fourth do not have appreciable right lower quadrant tenderness.
Only 20% of elderly patients present with anorexia, fever, right lower quadrant pain, and leukocytosis. The initial diagnosis is incorrect in 40-50% of patients in this age range.
All of the above factors contribute to delayed diagnosis and high complication rates. A 10-year retrospective review found that the diagnosis was delayed in 35% of patients (Lee, 2000). Again, a high index of suspicion is necessary to avoid missing this diagnosis.
Diverticulitis - The formation of diverticula in the colon is largely a product of diet and age and is relatively rare in those younger than 40 years. In the United States, diverticula are present in approximately 50-80% of patients older than 65 years.
Diverticulitis results when diverticula become obstructed by fecal matter, resulting in lymphatic obstruction, inflammation, and perforation. By definition, diverticulitis involves at least microperforation of the colon.
Approximately 85% of cases occur in the left colon. Right-sided diverticulitis is often more difficult to diagnose and generally is more benign.
Elderly patients with diverticulitis are often afebrile, and an elevated WBC count is observed in less than one half. Only approximately 25% of patients have guaiac positive stool.
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| docarchana
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so diverticulitis is the better ans
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| rashmi verma
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diverticular pain does not migrate, appendicitis pain does, so answer is appendicitis
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| docsrinu
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rashmi, diverticulitis has the same features as appendicitis except that it occurs on lt side.
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