What are the next steps for a patient with abdominal and pelvic pain, a computed tomography (CT) scan showing a metallic foreign body in the stomach, severe colonic diverticulosis, and liver changes suggestive of chronic hepatocellular disease?

Management of Patient with Abdominal Pain, Gastric Foreign Body, Diverticulosis, and Liver Changes

The most appropriate next step for this patient is urgent endoscopic removal of the metallic foreign body in the stomach, followed by CT scan with IV contrast to evaluate the diverticulosis and liver changes. 1

Gastric Foreign Body Management

Urgent Endoscopic Removal

• The CT scan shows a metallic foreign body within the cardia of the stomach, described as "presumably post biopsy"
• According to European Society of Gastrointestinal Endoscopy (ESGE) guidelines, urgent therapeutic esophagogastroduodenoscopy (within 24 hours) is recommended for foreign bodies in the stomach such as sharp-pointed objects, magnets, batteries, and large/long objects 1
• The metallic object in the stomach could be causing the patient's abdominal pain and requires prompt removal to prevent complications such as perforation, obstruction, or hemorrhage

Endoscopic Technique

• A protective device should be used during endoscopic extraction to avoid esophagogastric/pharyngeal damage and aspiration 1
• For metallic objects, specialized techniques may be employed:
  • Double-snare technique for long objects 2
  • Overtube method for safer removal of sharp objects 3, 4
  • Magnetic catheter for metallic items 5

Evaluation of Diverticulosis

CT Imaging

• After addressing the immediate concern of the gastric foreign body, a contrast-enhanced CT scan of the abdomen and pelvis is needed to properly evaluate the severe colonic diverticulosis 6
• CT is the imaging examination most widely used for diagnosing diverticulitis with high sensitivity and specificity 7
• CT can help differentiate between uncomplicated and complicated diverticulosis/diverticulitis 7

Assessment for Diverticulitis

• The patient's abdominal and pelvic pain could be related to diverticular disease
• CT findings that would suggest diverticulitis include:
  • Colonic wall thickening
  • Inflammatory changes in pericolic fat
  • Presence of pericolic fluid or abscess 6, 7
• The World Society of Emergency Surgery (WSES) guidelines recommend CT with IV contrast for suspected diverticulitis to determine the extent of disease and detect complications 6

Evaluation of Liver Changes

Liver Assessment

• The CT findings of "morphological changes of the liver suggestive of chronic hepatocellular disease" require further evaluation
• According to ACR Appropriateness Criteria, MRI abdomen without and with IV contrast or CT abdomen with IV contrast multiphase is usually appropriate for characterizing liver lesions in patients with known chronic liver disease 6
• After addressing the immediate concerns (foreign body and possible diverticulitis), a dedicated liver protocol MRI or multiphase CT should be considered to better characterize the liver changes

Follow-up Recommendations

1. Immediate/Urgent (within 24 hours):

   • Endoscopic removal of the gastric foreign body

2. Short-term (within 1-2 weeks):

   • CT abdomen and pelvis with IV contrast to properly evaluate the diverticulosis and rule out diverticulitis
   • Laboratory tests including CBC, liver function tests, and inflammatory markers (CRP)

3. Medium-term (within 1-2 months):

   • Depending on CT findings, consider MRI abdomen without and with IV contrast for better characterization of liver changes
   • Colonoscopy may be indicated to evaluate the extent of diverticular disease and rule out malignancy, particularly if the patient has complicated diverticulitis 7

Pitfalls to Avoid

• Delay in foreign body removal: Metallic objects in the stomach pose a risk of perforation and should be removed promptly 1
• Misdiagnosis of diverticulitis: Clinical suspicion alone is correct in only 40-65% of patients, necessitating imaging confirmation 7
• Overlooking liver disease: The liver changes require proper characterization as they may represent underlying chronic liver disease requiring specific management
• Inadequate follow-up: After foreign body removal, the patient should be monitored for complications and receive appropriate follow-up for both the diverticular disease and liver changes

By following this approach, you address the most urgent issue first (gastric foreign body) while ensuring proper evaluation and management of the other significant findings (diverticulosis and liver changes).