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General Surgery


Answer 3
  1. Abdominal/pelvic CT with oral contrast. A CT scan with oral contrast is the test of choice. If this is equivocal or suggestive of other pathology, one should next consider obtaining a Gastrografin enema.
    Although a leukocyte count may help demonstrate an infectious etiology, it is a relatively nonspecific test. A normal leukocyte count does not exclude an infectious process, and it is common for patients to have an increased leukocyte count because of factors such as dehydration or simply stress. The SMA-7 electrolytes are also nonspecific and usually represent the end result of the disease process; they are of limited benefit in determining the diagnosis of this patient’s abdominal symptoms.
    Abdominal films are most helpful for patients suspected of perforation or intestinal obstruction and for patients in whom the diagnosis is uncertain. This study may demonstrate free air, which would suggest an intestinal perforation.
    The use of ultrasound is limited in this situation. It is the test of choice in patients suspected of having gallbladder pathology. The kidneys, liver, and pancreas may also be evaluated with ultrasound; however, intestinal pathology is not well visualized with ultrasound.
    This patient most likely has an episode of acute diverticulitis. Because of the risk for perforation or peritonitis, barium enemas and sigmoidoscopy are usually reserved for patients who have recovered from an attack of acute diverticulitis.
    Other considerations in the differential diagnosis should include irritable bowel syndrome, appendicitis, inflammatory bowel disease, and pyelonephritis. All these diagnoses will be better delineated with the use of CT scan.

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