How to manage an 89-year-old patient with left lower quadrant (LLQ) pain and a newly identified inguinal hernia, with ultrasound (US) findings obscured by bowel gas and incidental cholelithiasis (gallstones)?

Management of an 89-year-old with LLQ Pain, Inguinal Hernia, and Incidental Cholelithiasis

CT scan of the abdomen and pelvis with IV contrast is the recommended next step for this 89-year-old patient with LLQ pain, newly identified inguinal hernia, and incidental cholelithiasis, as ultrasound findings are limited by bowel gas. 1, 2

Diagnostic Approach

The current ultrasound findings are inadequate for proper diagnosis due to bowel gas obscuring LLQ structures. This necessitates further imaging for appropriate management:

1. CT Abdomen and Pelvis with IV contrast:

   • Gold standard for evaluating LLQ pain with 98% accuracy 1, 2
   • Superior to ultrasound in detecting diverticulitis (sensitivity 81% vs 61%) 1
   • Better at revealing alternative diagnoses (sensitivity 50-100% vs 33-78% for ultrasound) 1
   • Can evaluate both the inguinal hernia and potential diverticulitis simultaneously
   • Can detect complications such as abscess formation, perforation, or bowel obstruction 1

2. Avoid plain radiography:

   • Extremely limited utility in this scenario
   • Only detects large amounts of free air or significant obstruction 1, 2
   • Cannot adequately evaluate soft tissue pathology

Differential Diagnosis to Consider

Given the patient's advanced age and presenting symptoms, several conditions must be considered:

• Diverticulitis: Common cause of LLQ pain in elderly patients 1
• Complicated inguinal hernia: May contain bowel and cause obstruction 1
• Strangulated hernia: Requires urgent surgical intervention 3
• Bowel obstruction: Can occur within the hernia sac 4
• Rare complications: Such as gallstones within hernia sac 5, 4

Management Algorithm

1. Immediate assessment:

   • Evaluate for signs of peritonitis, bowel obstruction, or strangulation
   • Check vital signs for evidence of systemic inflammatory response

2. Obtain CT scan with IV contrast:

   • Will provide definitive diagnosis and guide management 1, 2
   • Can identify complications requiring urgent intervention

3. Management based on CT findings:

   a) If uncomplicated diverticulitis:

   • Consider outpatient management with oral antibiotics if no comorbidities
   • Amoxicillin-clavulanate 875/125 mg orally twice daily for 4-7 days 2
   • Reassess in 48-72 hours

   b) If complicated diverticulitis:

   • Hospitalization for IV antibiotics
   • Surgical consultation
   • Percutaneous drainage for abscesses ≥3-4 cm 2

   c) If symptomatic inguinal hernia:

   • Surgical repair is recommended 3
   • Consider laparoscopic approach if patient is stable
   • Watchful waiting is not recommended for symptomatic hernias 3

   d) If both conditions require intervention:

   • Consider timing and approach of interventions
   • Simultaneous repair may be considered in select cases 6

Special Considerations for this Patient

• Advanced age (89 years): Higher risk of complications (9.7% mortality in patients 65-79 years) 2
• Incidental cholelithiasis: May not require immediate intervention unless symptomatic
• Potential for atypical presentation: Elderly patients often present with subtle or atypical symptoms 2

Warning Signs Requiring Urgent Evaluation

Instruct the patient to seek immediate medical attention if they develop:

• Fever
• Worsening abdominal pain
• Inability to tolerate oral intake
• Signs of peritonitis (rigid abdomen, rebound tenderness) 2

Follow-up Plan

• Schedule follow-up within 48-72 hours if managed as outpatient
• Consider colonoscopy 6-8 weeks after symptom resolution if diverticulitis is diagnosed, to rule out colon cancer 2
• Surgical planning for inguinal hernia repair once acute issues are resolved