What are the key components of a clinical exam for a patient presenting with diverticulitis?

Key Components of Clinical Examination for Diverticulitis

The clinical examination for diverticulitis must include assessment of left lower quadrant pain, fever, and leukocytosis, but these findings alone are insufficient for diagnosis as clinical suspicion without imaging is only accurate in 40-65% of cases. 1, 2

History Taking Components

• Abdominal pain characteristics:

  • Location: Typically left lower quadrant (67% of cases), but can present in right lower quadrant (24%) 3
  • Onset: Usually acute or subacute 1
  • Duration and progression
  • Aggravating/alleviating factors

• Associated symptoms:

  • Fever and chills (present in 71% of patients) 3
  • Nausea (present in 86% of patients) 3
  • Change in bowel habits (constipation or diarrhea) 1
  • Vomiting (less common than nausea) 1

• Risk factor assessment:

  • Age (increasing risk with age, especially >65 years)
  • Previous episodes of diverticulitis
  • Medications (NSAIDs, steroids, opioids)
  • Comorbidities (immunocompromised status, connective tissue diseases)

Physical Examination Elements

• Vital signs:

  • Temperature (fever >100.4°F suggests infection)
  • Heart rate (tachycardia, mean pulse rate of 103 ± 16 in young patients) 3
  • Blood pressure (hypotension may indicate sepsis)
  • Respiratory rate

• Abdominal examination:

  • Inspection for distension or visible mass
  • Auscultation for bowel sounds (decreased in ileus)
  • Palpation for:
    • Localized tenderness (left lower quadrant most common)
    • Rebound tenderness (suggests peritoneal irritation)
    • Guarding (involuntary or voluntary)
    • Palpable mass (suggests phlegmon or abscess)
  • Percussion for tympany or dullness

• Digital rectal examination:

  • Assess for tenderness, mass, or blood
  • Particularly important in elderly patients who may have atypical presentations 2

Laboratory Assessment

• Complete blood count (CBC):

  • Leukocytosis (present in 90% of patients) 3
  • Elevated neutrophil count

• C-reactive protein (CRP):

  • CRP >50 mg/L suggests diverticulitis
  • CRP >170 mg/L suggests severe diverticulitis 2

• Basic metabolic panel:

  • Assess for electrolyte abnormalities
  • Evaluate renal function

Imaging Studies

• CT abdomen/pelvis with IV contrast:

  • Gold standard for diagnosis
  • Sensitivity 98-99%, specificity 99-100% 2, 4
  • Findings include colonic wall thickening, pericolic fat stranding, diverticula

• Alternative imaging (when CT contraindicated):

  • Ultrasound: Sensitivity 61-90%, specificity 90-100% 2
  • MRI: High sensitivity but less specific than CT 1, 2
  • Plain radiographs: Limited utility for diagnosis but helpful for assessing complications like perforation or obstruction 1

Severity Assessment

• Uncomplicated vs. complicated diverticulitis:

  • Uncomplicated: Inflammation limited to colon wall and surrounding tissues
  • Complicated: Presence of abscess, peritonitis, obstruction, stricture, or fistula 1

• WSES Classification System 2:

  • Stage 1A: Pericolic air bubbles or small amount of pericolic fluid without abscess
  • Stage 1B: Abscess ≤4 cm
  • Stage 2A: Abscess >4 cm
  • Stage 2B: Distant gas >5 cm from inflamed bowel
  • Stage 3: Diffuse fluid without distant free gas
  • Stage 4: Diffuse fluid with distant free gas

Common Pitfalls and Caveats

1. Misdiagnosis risk: Clinical diagnosis alone has a misdiagnosis rate of 34-68% 2

2. Classic triad limitation: The classic triad of left lower quadrant pain, fever, and leukocytosis is present in only 25% of patients 2

3. Atypical presentations:

   • Right-sided diverticulitis may mimic appendicitis 5
   • Elderly patients often have atypical presentations with higher mortality rates 2
   • Immunocompromised patients may have minimal symptoms despite severe disease

4. Differential diagnosis considerations:

   • Appendicitis (especially with right-sided pain)
   • Colorectal cancer (can mimic diverticulitis)
   • Inflammatory bowel disease
   • Ischemic colitis
   • Urinary tract infection or pyelonephritis
   • Gynecological conditions in women

5. Follow-up planning:

   • Colonoscopy should be performed 6-8 weeks after resolution of acute symptoms to exclude malignancy 2
   • Contraindicated during acute diverticulitis due to risk of perforation 2

By systematically evaluating these clinical components, clinicians can better assess patients with suspected diverticulitis, though imaging confirmation remains essential for definitive diagnosis.