Q&A: Diagnosis Of New Onset Abdominal Pain in an Elderly Woman

Abdominal pain can be a challenging complaint for both primary care and specialist clinicians because it is frequently a benign complaint, but it can also herald serious acute pathology. The evaluation of abdominal pain requires an understanding of the possible mechanisms responsible for pain, a broad differential of common causes, and recognition of typical patterns and clinical presentations.

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This is a Question & Answer revision article designed for medical students and professionals preparing for the PLAB, MRCP or USMLE examinations. They are based on actual questions from these examinations. You may find the Digestive Health articles more useful, or one of our many articles on Diseases & Conditions, Medical Syndromes, Health & Wellness or Home Remedies.

In this article:
Neurologic basis for abdominal pain
MCQ exam: clinical scenario
MCQ exam: answer
MCQ exam: explanation

Neurologic basis for abdominal pain

Pain receptors in the abdomen respond to mechanical and chemical stimuli. Stretch is the principal mechanical stimulus involved in visceral nociception, although distention, contraction, traction, compression, and torsion are also perceived. Visceral receptors responsible for these sensations are located on serosal surfaces, within the mesentery, and within the walls of hollow viscera. Visceral mucosal receptors respond primarily to chemical stimuli, while other visceral nociceptors respond to chemical or mechanical stimuli.

MCQ exam: clinical scenario

A 70 year old female patient presents with new onset of left lower quadrant abdominal pain, a low-grade fever, focal tenderness with guarding and an elevated white blood cell count.

The most likely diagnosis is:

a) Endometrioma
b) Hemorrhagic ovarian cyst
c) Tubo-ovarian abscess
d) Ovarian torsion
e) Diverticulitis

MCQ exam: answer

The correct answer is E.

MCQ exam: explanation

The diagnosis of acute diverticulitis should be suspected in an older patient who presents with new onset of left lower quadrant abdominal pain, low-grade fever, focal tenderness with or without guarding, and an elevated white blood cell count. Nausea, vomiting, and diarrhea or constipation may accompany the bowel complaints and simulate gastroenteritis. Absence of bowel sounds suggests peritoneal inflammation.

In situations of diagnostic uncertainty, confirmatory testing can be obtained. Proctosigmoidoscopy performed with a flexible sigmoidoscope can be done comfortably, safely, and with a minimum of bowel preparation when it is essential to rule out other causes of serious colonic pathology, such as inflammatory bowel disease and cancer. Inability to pass the flexible sigmoidoscope beyond the rectosigmoid junction due to acute bowel inflammation is strongly suggestive of acute diverticulitis. Barium enema will identify diverticulitis; contrast outside the bowel lumen is an important diagnostic feature.

Reference(s)
1). UpToDate: Causes of abdominal pain in adults. Available online: https://www.uptodate.com/contents/causes-of-abdominal-pain-in-adults