What is the diagnosis for a 29-year-old male patient presenting with severe left lower quadrant (LLQ) abdominal pain, tenderness, and a history of ingesting foreign objects and chronic constipation?

From the Guidelines

This patient requires immediate imaging studies to evaluate for bowel obstruction or perforation, and I recommend an abdominal CT scan with contrast as the initial study, given its high sensitivity and specificity for diagnosing diverticulitis and other causes of left lower-quadrant pain, as supported by the American College of Physicians guideline 1. The patient's history of ingesting foreign objects and severe 10/10 pain in the left lower quadrant, combined with tenderness in the same area, raises significant concern for complications such as perforation, which can lead to peritonitis and sepsis if not addressed promptly. The chronic constipation may exacerbate the situation by causing impaction around any ingested foreign body, increasing the risk of bowel wall injury. Given the high risk of complications, I strongly recommend an abdominal CT scan with contrast, as it allows for the diagnosis of other causes of left lower-quadrant pain that may mimic diverticulitis, and it is particularly helpful in determining the extent and severity of disease, and in assessing for complications such as colonic perforation and abscess and fistula formation, as stated in the American College of Radiology Appropriateness Criteria 1. The patient should be kept NPO (nothing by mouth) until imaging results are available. IV access should be established for pain management with morphine 4-6mg IV or hydromorphone 0.5-1mg IV as needed for pain. IV fluid hydration with normal saline at 100-125 mL/hr should be initiated. Laboratory studies including CBC, CMP, and lactate level should be obtained to assess for signs of infection or ischemia. Surgical consultation should be requested early, as the patient may require urgent intervention if obstruction or perforation is confirmed. The use of antibiotics should be considered on a case-by-case basis, as the American College of Physicians suggests that clinicians initially manage select patients with acute uncomplicated left-sided colonic diverticulitis without antibiotics, unless there are signs of complicated diverticulitis or systemic inflammatory response 1. The patient's history and physical examination should guide the decision to use antibiotics, and the potential benefits and harms of antibiotic treatment should be carefully weighed. Informed decision making with the patient should include discussion of potential patient burdens related to CT imaging, including contraindications to use of contrast agents or limited access to CT imaging. Abdominal ultrasonography can be considered when CT cannot be obtained, and abdominal magnetic resonance imaging can be considered when ultrasonography provides inconclusive results. The patient's condition should be closely monitored, and any changes in symptoms or laboratory results should prompt a re-evaluation of the treatment plan. Given the complexity of the patient's condition, it is essential to prioritize a thorough diagnostic evaluation, including imaging studies and laboratory tests, to guide treatment decisions and minimize the risk of complications, as recommended by the American College of Physicians guideline 1. The patient's care should be coordinated with a multidisciplinary team, including surgeons, radiologists, and other specialists, to ensure that all aspects of the patient's condition are addressed. By prioritizing a thorough diagnostic evaluation and careful consideration of treatment options, we can minimize the risk of complications and improve the patient's outcomes, as supported by the American College of Physicians guideline 1. Key considerations in the patient's management include:

• The use of abdominal CT scan with contrast as the initial imaging study
• The potential benefits and harms of antibiotic treatment
• The importance of close monitoring and re-evaluation of the treatment plan
• The need for coordination of care with a multidisciplinary team
• The consideration of patient burdens and preferences in decision making.

From the Research

Patient Evaluation and Diagnosis

• The patient is a 29-year-old male presenting with abdominal pain in the left lower quadrant (LLQ) with a severity of 10/10, and has a history of ingesting foreign objects and chronic constipation 2.
• The patient's symptoms and medical history suggest the possibility of an intestinal obstruction or other gastrointestinal complications, which are common postoperative complications 3.
• Further imaging studies are necessary to evaluate the patient's condition and determine the best course of treatment.

Imaging Modalities for Diagnosis

• Computed tomography (CT) is usually the most appropriate and accurate diagnostic imaging modality for suspected bowel obstructions 2.
• Other commonly used imaging modalities include plain radiographs and contrast imaging/fluoroscopy, while less commonly utilized imaging modalities include ultrasonography and magnetic resonance imaging 2.
• A systematic and methodological approach to interpreting imaging results is essential to ensure diagnostic accuracy 2.
• The diagnostic performance of CT for small bowel obstruction has been evaluated in a systematic review and meta-analysis, which found that CT has considerable accuracy in diagnosis, with pooled sensitivity and specificity of 91% and 89%, respectively 4.

Potential Complications and Treatment

• The patient's condition may be at risk of developing into sepsis or septic shock, which are major causes of mortality among hospitalized patients 5.
• Early recognition and treatment of sepsis and septic shock are essential to reducing organ system injury and mortality 5.
• The patient's goals of care and treatment preferences should be considered, particularly if they have a serious illness or are at risk of decline 6.