Master the board step 3

Master the Boards: USMLE Step 3
Inflammation
Inflammatory causes of acute abdomen include the following:
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Acute diverticulitis
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Acute pancreatitis
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Acute appendicitis
The question will describe the following:
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Gradual onset of constant abdominal pain that slowly builds up over several
hours
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Initially ill-defined pain that eventually becomes localized to the site of
inflammation
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Note that signs of peritoneal irritation are absent in pancreatitis.
When diagnosing acute
diverticulitis, don’t forget to
order a urine pregnancy
test on all women of
childbearing age.
Acute Diverticulitis
Acute diverticulitis is one of the very few inflammatory processes presenting
with acute abdominal pain in the left lower quadrant. Look for a patient in
middle age or older with fever, leukocytosis, and peritoneal irritation in the
left lower quadrant with a palpable tender mass. In women, think about fallopian
tube and ovaries as potential sources.
Basic Science Correlate
The common location for diverticulosis is the sigmoid colon. This is because
it has the smallest diameter and therefore the highest intraluminal pressure.
Concurrently, the sigmoid has the highest degree of diverticulitis.
Colonoscopy is absolutely
contraindicated in acute
diverticulitis, as it raises the
risk of perforation.
Look out for the risk factors
for acute pancreatitis:
• Alcoholism
• Gallstones
• Medications
(didanosine,
pentamidine, Flagyl,
tetracycline, thiazides,
furosemide)
• Hypertriglyceridemia
• Trauma
• Post-ERCP
Diagnostic Testing
The most accurate diagnostic test is CT with contrast to look for abscess or free
air. Fat stranding is common around the inflamed bowel.
Treatment
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No peritoneal signs: Manage as outpatient with antibiotics.
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Localized peritoneal signs and abscess: Admit the patient. Order NPO, IV
fluids, IV antibiotics, and CT-guided percutaneous drainage of the abcess.
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Generalized peritonitis or perforation: Perform emergency surgery.
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Recurrent attacks of diverticulitis: Perform elective surgery.
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