Ileal diverticulitis: an uncommon diagnosis for right lower quadrant pain
A 75-year-old obese African-American woman presented to the emergency department with progressively worsening, severe and constant aching right lower quadrant pain for 3 days. She described the pain as starting in the epigastrium and moving to the right lower quadrant after 1 day. She vomited once 2 days ago, but denied current nausea, vomiting or diarrhea. Her last bowel movement was 1 day prior to admission. She denied fever, chills and urinary symptoms. Her past medical history included hypertension, diabetes mellitus and hypercholesterolemia. On examination, she was afebrile with stable vital signs. Palpation of the right lower quadrant elicited rebound tenderness and guarding. Bowel sounds were normoactive. Laboratory investigations were essentially within the normal range. Abdominal computed tomographic scan with oral and intravenous contrast media showed an inflammatory mass in the right lower quadrant and a small amount of free fluid on the right side of the pelvis and in the cul-de-sac (Fig. a and b). The appendix was not specifically identified. The patient was given a dose of Cefotetan and taken to the operating room for an open appendectomy. A transverse incision was made at McBurney's point and the appendix was visualized. It was noted that the appendix was extremely inflamed and thickened with mesentery down to the cecal base. Further exploration showed a large mass at the ileocecal junction involving the appendix (Fig. ). The appendix also had a necrotic base. In addition, multiple nodular masses were observed in the ileum and cecum. Because a carcinoma could not be excluded, the decision was made to perform a right hemicolectomy with primary anastomosis. Pathology revealed Ileal diverticulitis.