LEFT LOWER QUADRANT PAIN

LEFT LOWER QUADRANT PAIN: Excerpt from Differential Diagnosis in Primary Care

The anatomy of the left lower quadrant (LLQ), like that of the RLQ, will provide a basis for recalling the causes of pain. There are fewer structures to deal with; thus, the differential diagnosis is not difficult. Visualizing the structures layer by layer, there are the skin and abdominal wall in the first layer; the sigmoid colon, omentum, and portions of small intestine in the second layer; the ureter, fallopian tubes, and ovaries (in women) in the third layer; and the aorta, pelvis, and spine beneath all these structures. Now, by using the mnemonic VINDICATE, the organs can be cross-indexed with the various etiologies that may cause pain in this area (Table 10). The following discussion emphasizes the most important diseases that must be considered in the differential diagnosis.

ABDOMINAL PAIN, LLQ

1. Skin and abdominal wall. Herpes zoster, cellulitis, contusion, and, especially, inguinal or femoral hernias are significant causes of LLQ pain.
2. Small intestine. Regional ileitis, intussusception, adhesion, volvulus, and other conditions that cause intestinal obstruction should be considered here.
3. Sigmoid colon. Diverticulitis, ischemic colitis, mesenteric adenitis and infarct, and granulomatous colitis are important causes. Carcinoma of the sigmoid may induce pain by perforating or obstructing the colon.
4. Ureters. Ureteral colic must be considered in the differential diagnosis of LLQ pain.
5. Ovary and fallopian tubes. A mumps oophoritis, ovarian cysts that twist on their pedicles or rupture, and small graafian follicles of the normal cycle that rupture are all included in the differential diagnosis of LLQ pain. The tubes may cause pain if there is an ectopic pregnancy, or if they are inflamed by a salpingitis, or if they are infiltrated by endometriosis.
6. Aorta. Dissecting aneurysms and emboli of the terminal aorta may cause acute lower quadrant pain.
7. Pelvis and spine. Osteoarthritis, a ruptured disc, metastatic carcinoma, Pott disease, and rheumatoid spondylitis should be considered here.
8. Miscellaneous. Occasionally, pain in the bladder, prostate, or uterus is referred to the LLQ. A fibroid of the uterus may twist and cause pain. Impacted feces may cause severe pain. Referred pain from pneumonia, pleurisy, and myocardial infarction is uncommon but must be considered. Metabolic conditions that cause generalized abdominal pain and that should be remembered are listed on page 22.

Approach to the Diagnosis

There is no doubt about the value of a good history and physical examination, including both the rectal and pelvic areas. After this, the signs and symptoms should be summarized and grouped together; in many cases, this will pinpoint the diagnosis.

The laboratory workup can now proceed. In acute cases, the physician should order a flat plate of the abdomen, CBC, urinalysis (and examine it him- or herself), and serum amylase level before exploratory surgery. A pregnancy test is ordered in women of childbearing age. In chronic cases, sigmoidoscopy, barium enema, upper GI series, small-bowel follow-through, and stool for blood, ova, and parasites need to be done before culdoscopy, peritoneoscopy, or colonoscopy is contemplated. An exploratory laparotomy remains a useful diagnostic tool even in chronic cases of LLQ pain.

Other Useful Tests

1. CT scan of the abdomen and pelvis
2. Gallium or indium scan (diverticular abscess, tuboovarian abscess)
3. Sonogram (ruptured ectopic pregnancy)
4. IVP
5. Examine all urine for stones
6. Vaginal culture
7. Stool culture
8. Urine culture, sensitivity, and colony count
9. X-ray of lumbar spine (herniated disc, radiculopathy)
10. Peritoneal tap (ruptured ectopic pregnancy)
11. Aortogram (dissecting aneurysms)
12. Angiogram (mesenteric infarction)
13. Exploratory laparotomy

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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