What is the likely diagnosis and treatment for a patient with tenderness to palpation of the epigastric area, pain radiating to the throat upon climbing, and tenderness in the lower left quadrant, also positive on the obturator test?

Likely Diagnosis: Dual Pathology with Acute Diverticulitis and Gastroesophageal Reflux Disease

This patient presents with two distinct anatomical pain patterns requiring separate evaluation: epigastric pain radiating to the throat (suggesting GERD or esophagitis) and left lower quadrant tenderness with positive obturator sign (highly suggestive of acute left colonic diverticulitis). 1

Immediate Life-Threatening Conditions to Exclude

Cardiac Ischemia Must Be Ruled Out First

• Obtain ECG within 10 minutes of presentation and serial troponins at 0 and 6 hours, as myocardial infarction presents atypically with epigastric pain in 10-20% of cases with potentially fatal outcomes if missed 2, 3
• Never dismiss cardiac causes based on age or typical presentation alone 2

Perforated Viscus Assessment

• Examine for peritoneal signs including abdominal rigidity, rebound tenderness, and absent bowel sounds 2, 3
• Check vital signs for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation or sepsis 1, 2
• A positive obturator test (pain with internal rotation of flexed hip) specifically suggests pelvic inflammation or abscess, commonly seen with complicated diverticulitis 1

Diagnostic Workup Algorithm

Step 1: Laboratory Evaluation

• Complete blood count, C-reactive protein, and white blood cell count to assess inflammatory markers 1
• Serum lactate if sepsis suspected 3
• Cardiac troponins at 0 and 6 hours 2, 3

Step 2: Imaging Strategy

CT abdomen and pelvis with IV contrast is the gold standard and should be obtained immediately to confirm diverticulitis, assess for complications (abscess, perforation, fistula), and evaluate the upper GI tract 1

CT Findings for Diverticulitis:

• Intestinal wall thickening in the sigmoid/descending colon 1
• Pericolonic fat stranding and thickening of lateroconal fascia 1
• Extraluminal gas (97% in perforation), fluid or fat stranding (89%), ascites (89%), focal wall defect (84%) 1, 2
• Pericolonic or pelvic abscess formation 1

CT Findings for Upper GI Pathology:

• Distal esophageal wall thickening ≥5 mm suggests reflux esophagitis (56% sensitivity, 88% specificity) 1, 2
• Gastric or duodenal wall thickening, mucosal hyperenhancement, or focal outpouching from ulcerations 1

Treatment Based on Severity

For Uncomplicated Diverticulitis (No Abscess, No Perforation)

Antibiotics can be avoided in immunocompetent patients with CT-confirmed uncomplicated acute left colonic diverticulitis without significant comorbidities or signs of sepsis 1

• This recommendation is based on high-quality randomized trials showing antibiotic treatment neither accelerates recovery nor prevents complications in uncomplicated disease 1
• Clinical monitoring is essential to assess for resolution 1

For Complicated Diverticulitis

Small Abscesses (<3-4 cm):

• Antibiotic therapy alone for 7 days may be sufficient 1
• Broad-spectrum coverage: Ertapenem 1g q24h OR Eravacycline 1 mg/kg q12h 1

Large Abscesses (>3-4 cm):

• Percutaneous drainage combined with antibiotic therapy for 4 days is the preferred approach 1
• If percutaneous drainage not feasible and patient is critically ill or immunocompromised, surgical intervention should be considered 1

Septic Shock:

• Meropenem 1g q6h by extended infusion OR Doripenem 500mg q8h by extended infusion OR Imipenem/cilastatin 500mg q6h OR Eravacycline 1 mg/kg q12h 1

For GERD/Esophagitis Component

Initiate high-dose PPI therapy (omeprazole 20-40 mg once daily before meals) for the epigastric pain and throat radiation 2, 4

• Healing rates are 80-90% for acid-related pathology 2, 4
• Avoid NSAIDs as they worsen peptic ulcer disease and bleeding risk 2

Critical Clinical Pitfalls

The Positive Obturator Test is Highly Specific

• This finding strongly suggests pelvic inflammation or abscess formation, making complicated diverticulitis with abscess the most likely diagnosis for the left lower quadrant component 1
• Do not treat empirically without imaging confirmation, as the obturator test can also indicate appendicitis, pelvic abscess from other sources, or gynecologic pathology 5, 6

Dual Pathology Requires Dual Treatment

• The epigastric pain radiating to throat with climbing (exertional component) raises concern for both cardiac ischemia and GERD 1, 2
• Never attribute all symptoms to a single diagnosis when anatomically distinct pain patterns exist 7

Follow-Up Colonoscopy Considerations

• Routine colonoscopy after CT-confirmed acute diverticulitis is not warranted except for age-appropriate screening 1
• However, colonoscopy is indicated if abscess, local perforation, or fistula is identified (higher cancer risk) or if patient is >40 years with alarm features 1

Surgical Consultation Timing

• Immediate surgical consultation if peritoneal signs, hemodynamic instability, or diffuse peritonitis present 1, 3
• Delayed surgical consultation if percutaneous drainage fails or patient deteriorates despite appropriate medical management 1