Right-Sided Abdominal Pain with Contralateral (Left-Sided) Rebound Tenderness
This clinical presentation strongly suggests perforated sigmoid diverticulitis with diffuse peritonitis (Rovsing's sign variant), and you should immediately obtain CT imaging with IV contrast, initiate broad-spectrum antibiotics covering gram-negative and anaerobic organisms, resuscitate the patient, and prepare for urgent surgical consultation as this likely requires emergency Hartmann's procedure.
Understanding the Clinical Presentation
The finding of right-sided abdominal pain with rebound tenderness elicited on the left side represents a critical sign of peritoneal irritation that has spread beyond its point of origin. This pattern most commonly indicates:
- Perforated sigmoid diverticulitis with diffuse peritonitis extending across the peritoneal cavity 1
- The left lower quadrant pathology (sigmoid colon) causes inflammatory irritation that manifests as referred pain and peritoneal signs in the right abdomen 1
- This represents complicated acute left-sided colonic diverticulitis (ALCD) with perforation, which is a surgical emergency 1
Immediate Diagnostic Workup
Obtain CT scan with IV contrast immediately - this is the gold standard for diagnosing complicated diverticulitis and has positive and negative predictive values exceeding 0.95 and 0.99 respectively 1. Clinical examination alone has poor diagnostic accuracy (positive predictive value only 0.65) 1.
Laboratory assessment should include:
- C-reactive protein (CRP) - values >170-175 mg/L significantly discriminate severe from mild diverticulitis with 87.5% sensitivity and 91.1% specificity 1
- Complete blood count with white blood cell count 1
- Basic metabolic panel to assess for electrolyte derangements and renal function 1
- Lactate level if sepsis is suspected 1
Obtain blood cultures (at least 2 sets) before initiating antimicrobial therapy 1
Immediate Resuscitation and Medical Management
Begin goal-directed resuscitation immediately targeting mean arterial pressure ≥65 mmHg, with crystalloid fluids and vasopressors (norepinephrine first-line) if needed 1. The resuscitation phase should not exceed 6 hours, as time from admission to surgery beyond 6 hours in patients with GI perforation and septic shock results in 0% survival 1.
Initiate broad-spectrum IV antibiotics immediately after blood cultures covering gram-positive, gram-negative, and anaerobic organisms 1. The regimen must account for:
- Extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae, particularly if the patient has prior antibiotic exposure or comorbidities requiring concurrent antibiotics 1
- Local epidemiological resistance patterns 1
Antibiotic duration should be 4 days post-operatively if adequate source control is achieved, as longer courses provide no additional benefit 1
Surgical Management
Obtain urgent surgical consultation immediately - diffuse peritonitis from perforated diverticulitis requires emergency operative intervention 1.
For left-sided perforation with peritonitis, Hartmann's procedure is the procedure of choice 1. This involves:
- Resection of the diseased sigmoid colon
- Creation of an end colostomy
- Closure of the rectal stump
- This approach is rapid, minimizes surgical trauma, achieves source control, and eliminates risk of anastomotic leak in an unstable patient 1
Alternative approaches only if the patient is too unstable:
- Loop transverse colostomy for damage control if the patient cannot tolerate resection 1
- If open abdomen is required due to abdominal compartment syndrome, delay stoma creation and leave bowel stapled inside the abdominal cavity 1
Critical Pitfalls to Avoid
Do not delay surgery for prolonged resuscitation - source control must be achieved within 6 hours of admission in patients with perforation and septic shock 1. Brief resuscitation (few hours maximum) to prevent hemodynamic instability during anesthesia induction is appropriate, but prolonged delays are fatal 1.
Do not attempt primary anastomosis in this setting - the combination of fecal loading, impaired microcirculation from sepsis, and patient instability creates anastomotic leak rates of 4-13% in emergency settings compared to 0.5-1.4% electively 1. Hartmann's procedure eliminates this risk 1.
Do not rely on clinical examination alone - the diagnostic accuracy is poor and cross-sectional imaging changes management in a significant proportion of cases 1.
Do not withhold antibiotics in complicated diverticulitis - while uncomplicated diverticulitis without peritonitis may not require antibiotics, any patient with perforation, abscess, or peritonitis requires immediate antimicrobial therapy 1.
Special Considerations
If CT demonstrates a large abscess (>3cm) without free perforation, percutaneous drainage plus antibiotics may be attempted as a bridge to delayed elective surgery 1. However, diffuse peritonitis with contralateral rebound tenderness suggests free perforation rather than contained abscess 1.
Patients over age 40 should undergo colonoscopy after resolution to exclude underlying malignancy or Crohn's disease 1.