First, my apologies if my reply is duplication to others. I just read some of what was being posted and thought I might streamline the mental gymnastics. This is mostly for the medical students considering shelf exams, etc...
...there are also many old school ED docs who still feel diverticulitis is a physical diagnosis, and may say "40yo F c/o fever, LLQ pain x 2 days, Hx of DM, US r/o gyn pathology, elev WBC, diverticulitis?".
For med students:
gyn, bowel, or any other pathology can give you an elevated WBC. It is quite a non-specific finding.... you can actually get an elevation in WBC from a long night of binge drinking!!!
(see response towards end re: US or re-specified "eUS")
...US r/o of gyn culprits ...[40 is still a child bearing age] before zapping would confirm it via sigmoid thickening).
The general first step in considering a gyn pathology would likely be a urine or serum bHCG.... not US. In fact, US can and does miss a large amount of gyn path. US for gyn is often a secondary/confirmatory step.
...I was approaching the question as academic...If all the information I had was LLQ pain, fever, and thickening at sigmoid (seemed like a bit of an incomplete read (distention?, perfusion?)...the Hx of DM could even have been put there to suggest ischemic event (perhaps of the small intestine, not volvulus). WBC elevation would likely mean diverticulitis, but if accompanied by acidosis, this can rule in ischemia. If all we know is thickening at sigmoid without any other impressions (both from imaging studies and physical workup).
alot of points in this reply.
1. from an exam standpoint.... often all you get is the thickening. distention you should get from PE. Often, you don't get much information about perfusion.
2. Again, WBC elevation is not specific. Thus, I would avoid jumping to the conclusion, "elevation would likely mean diverticulitis".
3. Ischemia is ALWAYS a consideration in abdominal pain.... you often consider it in clinical context and disregard(or drop lower on DDx considerations) if clinical context is not suggestive. I don't think small bowel ischemia was ever anywhere in my top 20 DDx for LLQ pain... with thickened sigmoid. (note, I say "always", because you try to think of and quickly rule out the most deadly/dire things quickly. which is what I would do with any passing thought of SB ischemia in this scenario.)
4. WBC elevation and acidosis does NOT "rule in ischemia".
...Yes, in the usual clinical setting, small bowel ischemia rarely masquerades as diverticulitis, but maybe the question wanted us to consider that given that DM was mentioned..
That thought process will get you failed on written and oral board questions. The one thing the boards always reminds you is that the question is not meant to "trick you". If someone really wanted you to consider SB ischemia with LLQ pain and thickened sigmoid.... then it must be the 10th question in your third room at the oral exam and you have impressed them so much they are throwing everything they can think at you because you are smoking!!!
...I know I'm just reaching at things at this point...
Yes, overly so.
...I should've specified that I meant eUS for neoplasm as a further investigation...
Now to eUS.
1. you first went on about US to rule out gyn path. see my earlier reply.
2. eUS would NOT be an ED study.
3. eUS would not be my choice for ruling out gyn path.
4. eUS would be a consideration after identification of a tumor/malignancy in a specific setting. (see number 1, 2, & 3)
5. if you have a patient LLQ pain & thickened sigmoid, I would assess. treatment maybe non-operative or operative. Nonetheless, US would never be used by me in THIS clinical scenario in the acute setting. Once the patient gets past THIS acute setting....
complete colonoscopy around 6 weeks out from acute setting.
if neoplastic pathology found at colonoscopy, I would proceed to staging. eUS would be used depending on the findings at colonoscopy... i.e. location/etc...
...I just can't see EUS being anywhere in your treatment algorithm, especially if its utility is limited...It is definitely not the next step if you have a normal colonoscopy.....
I generally agree.... I would further go on and say eUS is not a modality I would use to "detect" a lesion so much as to define its depth/extent after already previously detected.
thus my penny.
again, I apologize if this was a duplicate of others.
J