We scanned the patient. The pt had perforated diverticulitis.
There are two teaching points in this case. (1) Be wary of borderline ua results. They may not be the cause of the pt’s illness. Doctors tend to over-treat borderline urinanalysis results; most of the urine cultures come back negative. (2) Patients with perforated diverticulitis (or any perforated bowel) may have surprisingly benign exams. In my area, we have a lot of young patients with diverticulitis, so a 30s M is not a surprise.
The CT shows a large collection of air / phlegmon, but no localized abscess. Note the difference between air in the bowel (green arrow, air is black on a ct scan, and it’s surrounded by a white border which is bowel wall) and air with no bowel wall around it (red arrow). Given its location in the pelvis, the most likely cause is perforated diverticulitis. The patient recovered with a few days of iv antibiotics. Perforated diverticulitis with abscess usually requires a trip to interventional radiology for drainage. If the patient doesn’t get better, they usually need to go to the OR.
Shout out to Fernando for the pick-up.