Right Lower Quadrant Mass

Right Lower Quadrant Mass: Excerpt from Differential Diagnosis in Primary Care

Anatomy is once again the key to developing a differential diagnosis of a right lower quadrant (RLQ) mass. Underneath the skin, subcutaneous tissue, fascia, and muscle, lie the cecum, appendix, terminal ileum, iliac artery and vein, and ileum. In the female, the fallopian tube and ovary should be included. Occasionally a ptosed kidney also will be felt here. Now, apply the etiologic mnemonic MINT to each organ, and you should have a reliable differential diagnosis, like that in Table 3. The important lesions to remember here are the following: M—Malformations such as inguinal and femoral hernias may be present. I—Inflammations include acute appendicitis with abscess, tubo-ovarian abscesses, and regional ileitis. N—Neoplasms to be considered in this area are carcinoma of the cecum and ovarian tumors. T—Traumatic lesions include fracture or contusion of the ileum and perforation of the bowel from a stab wound. The lymph nodes may be involved with tuberculosis or actinomycosis. The cecum may also be enlarged by accumulation of Ascaris or other parasites. The omentum can contribute to adhesions of the bowel to form a mass, or it may develop cysts.

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RIGHT LOWER QUADRANT MASS

	M	I	N	T
	Malformation	Inflammation	Neoplasm	Trauma
Skin	Sebaceous cyst	Abscess	Primary or metastatic carcinoma	Contusion
Subcutaneous Tissue and Fascia	Hernia	Cellulitis	Metastatic carcinoma Lipoma	Contusion
Cecum	Intussusception Diverticulum Intestinal obstruction	Diverticulitis Granulomatous colitis Parasites Amebiasis Ulcerative colitis	Carcinoma of the cecum	Perforation Contusion
Muscle		Psoas abscess Myositis		Contusion
Appendix	Fecalith	Appendicitis Appendiceal abscess	Carcinoid	Perforation
Terminal Ileum	Intussusception Meckel diverticulum Intestinal obstruction	Regional ileitis Typhoid Tuberculosis	Polyp Carcinoid Sarcoma	Perforation Contusion
Iliac Blood Vessels	Aneurysm	Thrombophlebitis
Lymph Nodes		Tuberculous adenitis	Metastatic tumor
Ilium		Osteomyelitis	Sarcoma	Fracture or contusion

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Approach to the Diagnosis

As with other abdominal masses, it is important to look for other symptoms and signs that will help determine the origin of the mass. If there are fever and chills, an appendiceal or diverticular abscess is possible. Blood in the stool suggests a diagnosis of colon carcinoma. If there is amenorrhea or vaginal bleeding in a woman of childbearing age, an ectopic pregnancy must be considered. A long history of chronic diarrhea with or without blood in the stools suggests Crohn disease. The initial workup will include a CBC, sedimentation rate, chemistry panel, stool for occult blood, pregnancy test, and flat plate of the abdomen. If there is fever and an acute presentation, consultation with a general surgeon to consider an immediate exploratory laparotomy is indicated. With a more insidious onset of the RLQ mass, the clinician has a choice of ordering a CT scan of the abdomen and pelvis after performing the initial diagnostic studies or proceeding systematically with a barium enema, IVP, or small-bowel series to determine the origin of the mass. A gastroenterology or gynecology consult may be the best way to resolve this dilemma.

Other Useful Tests

1. Sonogram (ectopic pregnancy)
2. Peritoneal tap (ruptured ectopic, peritoneal abscess)
3. Colonoscopy (colonic neoplasm)
4. Serum protein electrophoresis (plasmacytoma)
5. Indium scan (peritoneal abscess)
6. Aortogram (aortic aneurysm)
7. Lymphangiogram (retroperitoneal tumor)
8. Laparoscopy (neoplasm, ectopic pregnancy)

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LEFT LOWER QUADRANT MASS

	M	I	N	T
	Malformation	Inflammation	Neoplasm	Trauma
Skin	Sebaceous cyst	Abscess	Primary and metastatic carcinomas	Contusion
Subcutaneous Tissue and Fascia	Hernia	Cellulitis	Metastatic carcinoma Lipoma	Contusion
Muscle		Myositis		Contusion
Sigmoid Colon	Diverticulum Volvulus Intestinal obstruction	Diverticulitis and abscess Tuberculosis Granulomatous and ulcerative colitis	Carcinoma and polyp	Perforation Contusion Foreign body
Tube and Ovary	Hydatid cyst of Morgagni Ectopic pregnancy	Tubo-ovarian abscess	Ovarian cyst and carcinoma
Iliac Artery and Veins and Aorta	Aneurysm	Thrombophlebitis
Lymph Nodes		Tuberculous and acute infectious adenitis	Metastatic tumor
Ilium		Osteomyelitis	Sarcoma	Fracture or contusion

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Pictures

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• 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 MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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